Provider Demographics
NPI:1780014761
Name:CAROLINA CHILD NEUROLOGY, PLLC
Entity Type:Organization
Organization Name:CAROLINA CHILD NEUROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER AND ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHALAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:INDULKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-288-2454
Mailing Address - Street 1:1133 OFFSHORE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5250
Mailing Address - Country:US
Mailing Address - Phone:910-491-2437
Mailing Address - Fax:910-491-2439
Practice Address - Street 1:1540 PURDUE DR STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-491-2437
Practice Address - Fax:910-491-2439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDB6IQ3AG1EMedicare PIN