Provider Demographics
NPI:1801970173
Name:BRUCE P. DECARLO, MD, INC.
Entity type:Organization
Organization Name:BRUCE P. DECARLO, MD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-441-1242
Mailing Address - Street 1:373 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1040
Mailing Address - Country:US
Mailing Address - Phone:714-441-1242
Mailing Address - Fax:714-441-2449
Practice Address - Street 1:650 HOWE AVE
Practice Address - Street 2:SUITE 810
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4731
Practice Address - Country:US
Practice Address - Phone:916-927-3046
Practice Address - Fax:916-927-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA304681208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27552Medicare UPIN
CA00A346812Medicare ID - Type Unspecified