Provider Demographics
NPI:1912906140
Name:WOLNISTY, CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:WOLNISTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 SHERMAN DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-4001
Mailing Address - Country:US
Mailing Address - Phone:951-688-5122
Mailing Address - Fax:951-688-8145
Practice Address - Street 1:3838 SHERMAN DR
Practice Address - Street 2:SUITE 7
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4001
Practice Address - Country:US
Practice Address - Phone:951-688-5122
Practice Address - Fax:951-688-8145
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-08-03
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
CAG5804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR238ZOtherMEDICARE ID PTAN
CAA57374Medicare UPIN