Basic Information
Provider Information | |||||||||
NPI: | 1235585225 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLYLE | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 CEDAR ST # 3 | ||||||||
Address2: | YUSM DEPT OF ANESTHESIOLOGY | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037852802 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10000 SW INNOVATION WAY | ||||||||
Address2: |   | ||||||||
City: | PORT ST LUCIE | ||||||||
State: | FL | ||||||||
PostalCode: | 349872111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7723458100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2016 | ||||||||
LastUpdateDate: | 07/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ME151278 | FL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.