Provider Demographics
NPI:1104965193
Name:MACIAS, CARLOS (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MACIAS
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 1:1041 18TH ST
Mailing Address - Street 2:4
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4421
Mailing Address - Country:US
Mailing Address - Phone:424-364-5630
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLAZA SUITE 660
Practice Address - Street 2:UCLA CARDIAC ARRHYTHMIA CENTER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90092-7392
Practice Address - Country:US
Practice Address - Phone:310-206-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2005-0248207R00000X
CAHM274Z207R00000X
CAA119680207RC0001X, 207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHM274ZMedicare PIN