Healthcare Provider Details

I. General information

NPI: 1679560197
Provider Name (Legal Business Name): CARLA COLLINS GORUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 41ST AVE SUITE D
CAPITOLA CA
95010-2516
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 831-476-3000
  • Fax: 831-476-9009
Mailing address:
  • Phone: 916-379-2915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA86939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: