Provider Demographics
NPI:1760487292
Name:CARRION, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:CARRION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-2952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7800 PROVIDENCE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2952
Practice Address - Country:US
Practice Address - Phone:704-512-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30789208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4455597OtherAETNA
NC57543OtherMEDCOST
NC8921322Medicaid
NC12 60073OtherUNITED HEALTHCARE
NC21322OtherBCBS OF NC
NC12 60073OtherUNITED HEALTHCARE
NC4455597OtherAETNA