Basic Information
| Provider Information | |||||||||
| NPI: | 1720001142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UTTERBACK | ||||||||
| FirstName: | CARLIN | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 94220 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412473000 | ||||||||
| FaxNumber: | 5412473101 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 5TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974159702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414122000 | ||||||||
| FaxNumber: | 5414122081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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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 | 207Q00000X | MD126309 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500611363 | 05 | OR | MEDICAID | 93-0937095 | 01 | OR | CURRY HEALTH DISTRICT TAX ID | OTHER | 0000ZGBDG | 01 | OR | CURRY GEN. HOSP./BROOKINGS MED. CTR PART B | OTHER | 381322 | 01 | OR | CURRY GENERAL HOSPITAL PART A | OTHER | BU0124280 | 01 | OR | DEA | OTHER |