Basic Information
| Provider Information | |||||||||
| NPI: | 1912001207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLIS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233277 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Practice Location | |||||||||
| Address1: | 10110 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926464907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149634559 | ||||||||
| FaxNumber: | 7149630631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A4822 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0021844 | 05 | CA | MEDICAID |