Provider Demographics
NPI:1043339260
Name:CARRASCO PODIATRY CORPORATION
Entity Type:Organization
Organization Name:CARRASCO PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:951-212-6661
Mailing Address - Street 1:PO BOX 4347
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-4347
Mailing Address - Country:US
Mailing Address - Phone:951-212-6661
Mailing Address - Fax:909-987-3292
Practice Address - Street 1:7196 SUNNYSIDE PL
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-5995
Practice Address - Country:US
Practice Address - Phone:951-212-6661
Practice Address - Fax:909-987-3292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3608213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX69908Medicare UPIN
CACN388AMedicare PIN
CAZZZ22816ZMedicare PIN