Provider Demographics
NPI:1841212362
Name:WETZEL, CARROLL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:ROBERT
Last Name:WETZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-8171
Mailing Address - Fax:
Practice Address - Street 1:1602 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-885-8171
Practice Address - Fax:660-890-8490
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H39208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206786600Medicaid
C50890Medicare UPIN