Provider Demographics
NPI:1821092859
Name:CAPODANNO, CARMEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:C
Last Name:CAPODANNO
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 1:1360 W 6TH ST
Mailing Address - Street 2:STE 270
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3539
Mailing Address - Country:US
Mailing Address - Phone:310-831-1272
Mailing Address - Fax:310-831-1273
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:STE 270
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3539
Practice Address - Country:US
Practice Address - Phone:310-831-1272
Practice Address - Fax:310-831-1273
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA636220207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G362200Medicaid
CA00G362200Medicaid
CAA46614Medicare UPIN