Healthcare Provider Details

I. General information

NPI: 1003259664
Provider Name (Legal Business Name): RYAN CARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2013
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 WILSHIRE BLVD STE 101
SANTA MONICA CA
90403-5720
US

IV. Provider business mailing address

2350 W EL CAMINO REAL 2ND FLOOR
MOUNTAIN VIEW CA
94040-6201
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-0011
  • Fax: 310-828-2001
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM5283
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: