Provider Demographics
NPI:1386720787
Name:BOURNE, CARL WINSTON (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:WINSTON
Last Name:BOURNE
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 1:218 FALLEN LEAF DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4302
Mailing Address - Country:US
Mailing Address - Phone:707-447-4265
Mailing Address - Fax:707-453-7047
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:916-874-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49005207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89891Medicare UPIN