Basic Information
| Provider Information | |||||||||
| NPI: | 1194883793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORIS | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117581203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167952626 | ||||||||
| FaxNumber: | 5167997451 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117581203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165419700 | ||||||||
| FaxNumber: | 5167981086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 089458 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201285536 | 01 | EMPIRE | OTHER | 5491B1 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 5C4402 | 01 | HEALTH NET | OTHER | AP624 | 01 | OXFORD | OTHER | 4115108 | 01 | AETNA | OTHER | 089458 | 01 | HIP | OTHER | 5061 | 01 | VYTRA | OTHER | 5996232 | 01 | GHI | OTHER | P00230863 | 01 | RR MCR | OTHER | 201285536 | 01 | MAGNACARE | OTHER | 785722 | 01 | CIGNA | OTHER | 00404884 | 05 | NY | MEDICAID | 201285536 | 01 | UNITED HEALTHCARE | OTHER |