Provider Demographics
NPI:1730178450
Name:VOLLBERG, CARLTON MARK (DO)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:MARK
Last Name:VOLLBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 GUNBARREL RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7197
Mailing Address - Country:US
Mailing Address - Phone:423-296-0382
Mailing Address - Fax:423-296-0383
Practice Address - Street 1:1608 GUNBARREL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7197
Practice Address - Country:US
Practice Address - Phone:423-296-0382
Practice Address - Fax:423-296-0383
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND01391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4134244OtherBLUE CROSS
TN4134244OtherBLUE CROSS
TNF66407Medicare UPIN