Basic Information
| Provider Information | |||||||||
| NPI: | 1710942859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7166301054 | ||||||||
| Practice Location | |||||||||
| Address1: | 277 DIVISION ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141204667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166943541 | ||||||||
| FaxNumber: | 7166943543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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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 | 207RC0000X | 190642 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0661027 | 05 | NY | MEDICAID |