Provider Demographics
NPI:1811988231
Name:PENCE, CARLA R (MD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:R
Last Name:PENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:PO BOX 1845
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4353
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-873-4511
Practice Address - Street 1:1818 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3524
Practice Address - Country:US
Practice Address - Phone:704-873-1036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966728Medicaid
NC8966728Medicaid
NC203844JMedicare PIN
NCC82111Medicare UPIN