Provider Demographics
NPI:1407514169
Name:CARMEN RUIZ MD INC
Entity Type:Organization
Organization Name:CARMEN RUIZ MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-605-8140
Mailing Address - Street 1:7439 LA PALMA AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2655
Mailing Address - Country:US
Mailing Address - Phone:714-522-2001
Mailing Address - Fax:714-522-7503
Practice Address - Street 1:222 W EULALIA ST STE 100A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2850
Practice Address - Country:US
Practice Address - Phone:818-277-0567
Practice Address - Fax:818-244-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC146537OtherMEDICAL LICENSE
CA1003886490Medicaid