Provider Demographics
NPI:1144271370
Name:BRUMBAUGH, CARLA J (MD)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:J
Last Name:BRUMBAUGH
Suffix:
Gender:F
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:PO BOX 5602
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5602
Mailing Address - Country:US
Mailing Address - Phone:260-471-9466
Mailing Address - Fax:260-484-5919
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1702
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010412672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092606OtherANTHEM
ING06238Medicare UPIN
IN163520CMedicare ID - Type Unspecified
IN194930BMedicare ID - Type Unspecified
IN925240VMedicare ID - Type Unspecified
IN147380UMedicare ID - Type Unspecified
IN191150DMedicare ID - Type Unspecified
IN000000092606OtherANTHEM
IN924750IMedicare ID - Type Unspecified
IN055740XMedicare ID - Type Unspecified