Basic Information
| Provider Information | |||||||||
| NPI: | 1518312453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTAGENA DE JESUS | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARTAGENA | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 73720 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997073720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NOBLE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2016 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R75496 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 143269 | AK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1698143 | 05 | AK | MEDICAID |