Provider Demographics
NPI:1831675537
Name:CARRIE L CARDENAS MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CARRIE L CARDENAS MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARDENAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-819-7227
Mailing Address - Street 1:3330 3RD AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5639
Mailing Address - Country:US
Mailing Address - Phone:619-819-7227
Mailing Address - Fax:619-299-7430
Practice Address - Street 1:3330 3RD AVE STE 402
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5639
Practice Address - Country:US
Practice Address - Phone:619-819-7227
Practice Address - Fax:619-299-7430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA727440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A727440Medicaid
CAA72744OtherTHE MEDICAL BOARD OF CALIFORNIA