Provider Demographics
NPI:1003886490
Name:RUIZ, CARMEN (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:RUIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W EULALIA ST STE 100A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2850
Mailing Address - Country:US
Mailing Address - Phone:818-244-8161
Mailing Address - Fax:
Practice Address - Street 1:222 W EULALIA ST STE 100A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2850
Practice Address - Country:US
Practice Address - Phone:818-244-8161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC146537208C00000X
OK23551208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019610BMedicaid
248402003Medicare ID - Type Unspecified
OK200019610BMedicaid