Provider Demographics
NPI:1306897103
Name:PERCIVAL, CARLISLE JAMES (MD)
Entity type:Individual
Prefix:
First Name:CARLISLE
Middle Name:JAMES
Last Name:PERCIVAL
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8250
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:619-537-6000
Practice Address - Fax:916-851-2884
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43092207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G430920Medicaid
CAHE894YMedicare PIN
CAHE894ZMedicare PIN
CAHE894XMedicare PIN
CAP01538286Medicare PIN
CA00G430920Medicaid
CA00G430920Medicaid