Provider Demographics
NPI:1043221245
Name:BENEDICT T. CAROTA MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BENEDICT T. CAROTA MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:T
Authorized Official - Last Name:CAROTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-637-1655
Mailing Address - Street 1:901 SUNSET DR
Mailing Address - Street 2:STE 1
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023
Mailing Address - Country:US
Mailing Address - Phone:831-637-1655
Mailing Address - Fax:831-637-6894
Practice Address - Street 1:901 SUNSET DR
Practice Address - Street 2:STE 1
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023
Practice Address - Country:US
Practice Address - Phone:831-637-1655
Practice Address - Fax:831-637-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA363590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03874ZMedicare PIN