Basic Information
| Provider Information | |||||||||
| NPI: | 1609829746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANGSNESS | ||||||||
| FirstName: | CARLETON | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900310309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425860 | ||||||||
| FaxNumber: | 3234426296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234425860 | ||||||||
| FaxNumber: | 3234426990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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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 | 207X00000X | G56949 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | G56949 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G569490 | 05 | CA | MEDICAID | 00G569490 | 01 | CA | BLUE SHIELD | OTHER |