Basic Information
| Provider Information | |||||||||
| NPI: | 1326245655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUEL-PARKS | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAMUEL | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668107 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 COMMERCIAL DR | ||||||||
| Address2: | |||||||||
| City: | MAHOMET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618538625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175866600 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036124333 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.