Provider Demographics
NPI:1609892769
Name:PITTARD, CARLTON D (MD)
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:D
Last Name:PITTARD
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 1:1280 S MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7509
Mailing Address - Country:US
Mailing Address - Phone:817-310-0014
Mailing Address - Fax:817-416-4659
Practice Address - Street 1:1280 S MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7509
Practice Address - Country:US
Practice Address - Phone:817-310-0014
Practice Address - Fax:817-416-4659
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC6476208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102579305Medicaid
TX102579304Medicaid
TXB25534Medicare UPIN
TX8904B6Medicare ID - Type Unspecified
TX102579305Medicaid