Provider Demographics
NPI:1376620781
Name:CARLOS B EVERETT, M.D.
Entity Type:Organization
Organization Name:CARLOS B EVERETT, M.D.
Other - Org Name:PORT MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-887-0584
Mailing Address - Street 1:917 S PORT AVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-2301
Mailing Address - Country:US
Mailing Address - Phone:361-887-0584
Mailing Address - Fax:361-887-0586
Practice Address - Street 1:917 S PORT AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-2301
Practice Address - Country:US
Practice Address - Phone:361-887-0584
Practice Address - Fax:361-887-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080577201Medicaid
TX080577201Medicaid