Provider Demographics
NPI:1194915926
Name:CORK, CARLA (DO)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:CORK
Suffix:
Gender:F
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:PO BOX 7140
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7140
Mailing Address - Country:US
Mailing Address - Phone:317-501-0210
Mailing Address - Fax:317-236-6054
Practice Address - Street 1:5555 N TACOMA AVE
Practice Address - Street 2:SUITE, 12
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3512
Practice Address - Country:US
Practice Address - Phone:317-501-0210
Practice Address - Fax:317-236-6054
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003708A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201178190Medicaid
IN201178190Medicaid