Healthcare Provider Details

I. General information

NPI: 1851509244
Provider Name (Legal Business Name): CAROL VANPETTEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL VAN PETTEN M.D.

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPT NEUROLOGY KAISER PERMANENTE 10800 MAGNOLIA AVE
RIVERSIDE CA
92505
US

IV. Provider business mailing address

DEPT. NEUROLOGY 10800 MAGNOLIA AVE
RIVERSIDE CA
92505
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-4746
  • Fax:
Mailing address:
  • Phone: 951-353-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberGO59609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: