Provider Demographics
NPI:1265482129
Name:VENTOCILLA, CARMEN R (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:R
Last Name:VENTOCILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3960 PATIENT CARE WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4275
Mailing Address - Country:US
Mailing Address - Phone:517-351-8123
Mailing Address - Fax:517-351-1352
Practice Address - Street 1:3960 PATIENT CARE WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4275
Practice Address - Country:US
Practice Address - Phone:517-351-8123
Practice Address - Fax:517-351-1352
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MICV405064208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI25008734OtherRAILROAD MEDICARE
MI0331111OtherBCBSM
MI25008734OtherRAILROAD MEDICARE
MI0331111OtherBCBSM