Provider Demographics
NPI:1063621738
Name:CENTRO MEDICO DEL CARMEN, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CENTRO MEDICO DEL CARMEN, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-480-9051
Mailing Address - Street 1:303 S JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4924
Mailing Address - Country:US
Mailing Address - Phone:760-480-9051
Mailing Address - Fax:760-480-9054
Practice Address - Street 1:303 S JUNIPER ST
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4924
Practice Address - Country:US
Practice Address - Phone:760-480-9051
Practice Address - Fax:760-480-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52193208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A521930Medicaid
CA00A521930Medicaid
CAW19646Medicare ID - Type Unspecified