Basic Information
| Provider Information | |||||||||
| NPI: | 1942650189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 W 149TH ST | ||||||||
| Address2: | APT. 53 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100313612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524062234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | BRONX-LEBANON HOSPITAL CENTER | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189601417 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2016 | ||||||||
| LastUpdateDate: | 06/19/2016 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.