Provider Demographics
NPI:1922233873
Name:PRINCE BOLIVAR, CARLA (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:PRINCE BOLIVAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-3000
Mailing Address - Fax:573-331-5073
Practice Address - Street 1:515 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1919
Practice Address - Country:US
Practice Address - Phone:573-760-7920
Practice Address - Fax:573-756-9597
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009022078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine