Provider Demographics
NPI:1518312453
Name:CARTAGENA DE JESUS, CARLA MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MICHELLE
Last Name:CARTAGENA DE JESUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:MICHELLE
Other - Last Name:CARTAGENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:907-459-3500
Mailing Address - Fax:907-459-3526
Practice Address - Street 1:1001 NOBLE ST STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4991
Practice Address - Country:US
Practice Address - Phone:907-459-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR75496208000000X
AK143269208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1698143Medicaid