Healthcare Provider Details

I. General information

NPI: 1972038222
Provider Name (Legal Business Name): CARLO ANDREI DE LA SANCHA VERDUZCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 04/02/2023
Certification Date: 04/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE RM 114
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

350 W 11TH ST SUITE 4083
INDIANAPOLIS IN
46202-4108
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-6068
  • Fax:
Mailing address:
  • Phone: 317-274-2476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11019158A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberA171656
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberA171656
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA171656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: