Basic Information
Provider Information | |||||||||
NPI: | 1740634880 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CERVANTES | ||||||||
FirstName: | CARMEN ELENA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CERVANTES PACURUCU | ||||||||
OtherFirstName: | CARMEN ELENA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2401 DEMERS AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 58201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017801891 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1830 E. MONUMENT ST. | ||||||||
Address2: | 4TH FLOOR / SUITE 416 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 21287 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109555268 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2016 | ||||||||
LastUpdateDate: | 07/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 11/28/2016 | ||||||||
NPIReactivationDate: | 12/16/2016 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D90474 | MD | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207RN0300X | D90474 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.