Provider Demographics
NPI:1679653802
Name:ST LAURENT, CARLA (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:ST LAURENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:9920 TALBERT AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-378-7000
Practice Address - Fax:714-647-1245
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63787207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA63787CMedicare PIN
CACB212331Medicare PIN
CAH46989Medicare UPIN