Provider Demographics
NPI:1225017122
Name:DE LA GARZA, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:DE LA GARZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:2412 WILKINS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-7268
Practice Address - Country:US
Practice Address - Phone:919-776-6000
Practice Address - Fax:919-776-0130
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28019173000000X
NC8428019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1225017122Medicaid
NCAD2874053OtherDEA
NCCN8132OtherMEDICARE RAILROAD
NC8928286Medicaid
NCAD2874053OtherDEA