Provider Demographics
NPI:1841471166
Name:RUSSELL P CARTER JR MD INC
Entity type:Organization
Organization Name:RUSSELL P CARTER JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:209-239-4554
Mailing Address - Street 1:200 COTTAGE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4935
Mailing Address - Country:US
Mailing Address - Phone:209-239-4554
Mailing Address - Fax:209-239-4011
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-239-4554
Practice Address - Fax:209-239-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G355730Medicaid
CAA46406Medicare UPIN