Provider Demographics
NPI:1003172859
Name:GROVHOUG, CARLY (MD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GROVHOUG
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:111 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:CA
Practice Address - Zip Code:95694-1930
Practice Address - Country:US
Practice Address - Phone:530-795-4591
Practice Address - Fax:530-795-0315
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine