Provider Demographics
NPI:1558361659
Name:GARRISON, CARLA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:KESTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1530 E. BRADFORD PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4213
Mailing Address - Country:US
Mailing Address - Phone:417-877-0630
Mailing Address - Fax:417-877-0695
Practice Address - Street 1:1530 E. BRADFORD PARKWAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4213
Practice Address - Country:US
Practice Address - Phone:417-877-0630
Practice Address - Fax:417-877-0695
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203402029Medicaid
MO000095225Medicare PIN
MOF24910Medicare UPIN