Basic Information
| Provider Information | |||||||||
| NPI: | 1225017122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA GARZA | ||||||||
| FirstName: | CARLOS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208775 | ||||||||
| Practice Location | |||||||||
| Address1: | 2412 WILKINS DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273307268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197766000 | ||||||||
| FaxNumber: | 9197760130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 28019 | NC | N | Other Service Providers | Legal Medicine | 207Q00000X | 8428019 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1225017122 | 05 | NC | MEDICAID |