Provider Demographics
NPI:1235220864
Name:CARUSO, MICHAEL ANDRES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDRES
Last Name:CARUSO
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 1:10969 TOLLS LN
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6532
Mailing Address - Country:US
Mailing Address - Phone:909-796-9014
Mailing Address - Fax:
Practice Address - Street 1:24785 STEWART ST STE 111
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1721
Practice Address - Country:US
Practice Address - Phone:909-558-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A868580Medicare PIN