Provider Demographics
NPI:1023099181
Name:NORDSTROM, CARL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:ROBERT
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 E OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4249
Mailing Address - Country:US
Mailing Address - Phone:704-550-5860
Mailing Address - Fax:
Practice Address - Street 1:739 E OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-4249
Practice Address - Country:US
Practice Address - Phone:704-550-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0022424207Q00000X
NC22424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC63026OtherBC/BS
080100464OtherRAIL ROAD MEDICARE
NC8963026Medicaid
080100464OtherRAIL ROAD MEDICARE
NCC81134Medicare UPIN
NC202197FMedicare PIN
NC8963026Medicaid
NC202197DMedicare PIN