Provider Demographics
NPI:1013195718
Name:PATRICK, CARLETUS M (IDC)
Entity Type:Individual
Prefix:
First Name:CARLETUS
Middle Name:M
Last Name:PATRICK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 SAN BERNARDINO AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-4650
Mailing Address - Country:US
Mailing Address - Phone:619-694-9040
Mailing Address - Fax:
Practice Address - Street 1:2450 CRAVEN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5599
Practice Address - Country:US
Practice Address - Phone:619-556-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman