MEDICARE: MRS. CARLA DU MONT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G75999	CA

General Provider Information

NPI Number	:	1104194679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLA DU MONT

Provider Business Mailing Address
First Line	:	29 ST TROPEZ
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-6834
Country	:	US
Telephone Number	:	760-218-0523
Fax Number	:

Provider Business Practice Location Address
First Line	:	29 SAINT TROPEZ
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-6834
Country	:	US
Telephone Number	:	760-218-0523
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	01/31/2012

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