Healthcare Provider Details

I. General information

NPI: 1508203183
Provider Name (Legal Business Name): CODY SHERIDAN CARTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST RM 2516
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON ST RM 2516
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4094
  • Fax:
Mailing address:
  • Phone: 909-558-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number4301102984
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA159218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: