Provider Demographics
NPI:1790773596
Name:CARELOCK, DAVID P (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:CARELOCK
Suffix:
Gender:M
Credentials:CRNA
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 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-3611
Practice Address - Fax:254-200-4090
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX637274367500000X
CANA3375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX006844701Medicaid
TX00C073MOtherBLUE CROSS BLUE SHIELD
TX109873101OtherFIRSTCARE
TX00026CMedicare ID - Type Unspecified
TXS60216Medicare UPIN
CAHB421ZMedicare PIN