Provider Demographics
NPI:1437265352
Name:SELIN, CARL R (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:R
Last Name:SELIN
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 1:17400 IRVINE BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:714-838-5610
Mailing Address - Fax:
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-838-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1437265352OtherNPI
CA1689633125OtherGRP.NPI
CAW1779OtherMEDICARE GRP #
CAW1779OtherMEDICARE GRP #
CAWA20803AMedicare PIN