Provider Demographics
NPI:1043315880
Name:MCCARTY, DOUGLAS GORDON I (PHYSICAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:GORDON
Last Name:MCCARTY
Suffix:I
Gender:M
Credentials:PHYSICAN ASSISTANT
Other - Prefix:MR
Other - First Name:DOUG
Other - Middle Name:GORDON
Other - Last Name:MCCARTY
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:PO BOX 1958
Mailing Address - Street 2:32382 PINE MANOR LANE
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-1958
Mailing Address - Country:US
Mailing Address - Phone:909-800-1121
Mailing Address - Fax:909-867-2852
Practice Address - Street 1:12980 FREDERICK ST STE I
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5263
Practice Address - Country:US
Practice Address - Phone:951-924-3244
Practice Address - Fax:951-243-6976
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant