Provider Demographics
NPI:1609812650
Name:CARSON, GARY M (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:CARSON
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:PO BOX 8117
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080
Mailing Address - Country:US
Mailing Address - Phone:530-529-1306
Mailing Address - Fax:530-529-4951
Practice Address - Street 1:1133 W SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988
Practice Address - Country:US
Practice Address - Phone:530-934-1800
Practice Address - Fax:530-934-1865
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48501207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A485010Medicaid
E78237Medicare UPIN
CA00A485016Medicare PIN
CA00A485010Medicaid