Provider Demographics
NPI:1073579785
Name:PADILLA, CARLOS R (DO)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:PADILLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-7181
Mailing Address - Fax:810-606-7174
Practice Address - Street 1:4632 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8067
Practice Address - Country:US
Practice Address - Phone:810-606-7181
Practice Address - Fax:810-606-7174
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015882208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4614885Medicaid
M61910Medicare PIN
A16046Medicare UPIN