1043315880 NPI number — MR. DOUGLAS GORDON MCCARTY I PHYSICAN ASSISTANT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043315880 NPI number — MR. DOUGLAS GORDON MCCARTY I PHYSICAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCARTY
Provider First Name:
DOUGLAS
Provider Middle Name:
GORDON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
PHYSICAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCARTY
Provider Other First Name:
DOUG
Provider Other Middle Name:
GORDON
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
I
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043315880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1958
Provider Second Line Business Mailing Address:
32382 PINE MANOR LANE
Provider Business Mailing Address City Name:
RUNNING SPRINGS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92382-1958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-800-1121
Provider Business Mailing Address Fax Number:
909-867-2852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12980 FREDERICK ST STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-5263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-924-3244
Provider Business Practice Location Address Fax Number:
951-243-6976
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA11412 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com