Provider Demographics
NPI:1366944258
Name:REX, CARL WILLIAM
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:WILLIAM
Last Name:REX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22W284 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MEDINAH
Mailing Address - State:IL
Mailing Address - Zip Code:60157-9504
Mailing Address - Country:US
Mailing Address - Phone:630-209-8398
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST BLDG 200
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1563
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:415-750-6603
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program