MEDICARE: DR. CARLETON THOMAS VANGSNESS JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	G56949	CA
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	G56949	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00G569490	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1609829746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLETON THOMAS VANGSNESS JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 31309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-0309
Country	:	US
Telephone Number	:	323-442-5860
Fax Number	:	323-442-6296

Provider Business Practice Location Address
First Line	:	1520 SAN PABLO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5314
Country	:	US
Telephone Number	:	323-442-5860
Fax Number	:	323-442-6990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	09/30/2016

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