Healthcare Provider Details

I. General information

NPI: 1912001207
Provider Name (Legal Business Name): SAMUEL ALAN CARLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 ADAMS AVE
HUNTINGTON BEACH CA
92646-4907
US

IV. Provider business mailing address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

V. Phone/Fax

Practice location:
  • Phone: 714-963-4559
  • Fax: 714-963-0631
Mailing address:
  • Phone: 949-923-3277
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: