Provider Demographics
NPI:1114983913
Name:PESTA, CARL MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:MATTHEW
Last Name:PESTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 HARRINGTON ST
Mailing Address - Street 2:SUITE 302A
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:586-759-2005
Mailing Address - Fax:586-759-2636
Practice Address - Street 1:1030 HARRINGTON ST
Practice Address - Street 2:302A
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2967
Practice Address - Country:US
Practice Address - Phone:586-759-2005
Practice Address - Fax:586-759-2636
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013083208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114446930Medicaid
MI0255003665OtherBCBS PIN
MIH44628Medicare UPIN
MI0N76210003Medicare PIN