1710942859 NPI number — DAVID EUGENE CARLSON JR. M.D.

Table of content: DAVID EUGENE CARLSON JR. M.D. (NPI 1710942859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710942859 NPI number — DAVID EUGENE CARLSON JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
DAVID
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710942859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6255 SHERIDAN DR
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-4836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-857-8666
Provider Business Mailing Address Fax Number:
716-630-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 DIVISION ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
NORTH TONAWANDA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14120-4667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-694-3541
Provider Business Practice Location Address Fax Number:
716-694-3543
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  190642 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0661027 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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