Provider Demographics
NPI:1417063306
Name:GERDES, CAROL A (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:GERDES
Suffix:
Gender:F
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:PO BOX 211414
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91921-1414
Mailing Address - Country:US
Mailing Address - Phone:619-600-4230
Mailing Address - Fax:866-633-4209
Practice Address - Street 1:501 S SHORE CTR W
Practice Address - Street 2:SUITE D
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5762
Practice Address - Country:US
Practice Address - Phone:510-864-0660
Practice Address - Fax:510-864-0393
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62236207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G622360Medicaid
CA00G622360Medicare ID - Type Unspecified
F75496Medicare UPIN