Provider Demographics
NPI:1124473749
Name:BLACK, CARLA MARIE (MD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6640 INTECH BLVD STE 195
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2014
Practice Address - Country:US
Practice Address - Phone:317-295-0608
Practice Address - Fax:317-948-0609
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087770A208000000X, 2084P0800X, 2084P0804X
LA3101682084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102529646OtherANTHEM PTAN
IN300062282Medicaid