Provider Demographics
NPI:1184052730
Name:ISLAS, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:ISLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 SIERRA MADRE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6757
Mailing Address - Country:US
Mailing Address - Phone:714-414-1035
Mailing Address - Fax:
Practice Address - Street 1:1624 SIERRA MADRE CIR
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6626
Practice Address - Country:US
Practice Address - Phone:714-414-1035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAA82060207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies