Provider Demographics
NPI:1679871362
Name:MENJIVAR, CARLINA MARISOL (MD)
Entity type:Individual
Prefix:
First Name:CARLINA
Middle Name:MARISOL
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S. COOLIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1863
Mailing Address - Country:US
Mailing Address - Phone:509-765-0674
Mailing Address - Fax:509-765-6591
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1893
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:509-765-6591
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115165207Q00000X
WAMD60373874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8923757Medicare PIN