Provider Demographics
NPI:1528049988
Name:CARTER, RUSSELL P JR (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:P
Last Name:CARTER
Suffix:JR
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 1:200 COTTAGE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336
Mailing Address - Country:US
Mailing Address - Phone:209-239-4554
Mailing Address - Fax:209-239-4011
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-239-4554
Practice Address - Fax:209-239-4011
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G355730Medicaid
CAA46406Medicare UPIN