Provider Demographics
NPI:1356332001
Name:FOSSO, CAROL K (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:K
Last Name:FOSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:K
Other - Last Name:FOSSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:70 E 91ST ST STE 204
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1564
Mailing Address - Country:US
Mailing Address - Phone:317-872-4213
Mailing Address - Fax:317-872-6388
Practice Address - Street 1:70 E 91ST ST STE 204
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1564
Practice Address - Country:US
Practice Address - Phone:317-872-4213
Practice Address - Fax:317-872-6388
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1037197207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100132220Medicaid
IN100132220Medicaid
E09525Medicare UPIN