Provider Demographics
NPI:1073573127
Name:CARRASCO, PETE JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETE
Middle Name:
Last Name:CARRASCO
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:909-899-0258
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
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE-3608213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT90636Medicare UPIN