Provider Demographics
NPI:1982875704
Name:CARL WOLNISTY MD INC
Entity Type:Organization
Organization Name:CARL WOLNISTY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLNISTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-688-5122
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:92503-4098
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:92503-4098
Practice Address - Country:US
Practice Address - Phone:951-688-5122
Practice Address - Fax:951-688-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR239AOtherMEDICARE PTAN
CA000G58040Medicare UPIN
CAA57374Medicare UPIN