Provider Demographics
NPI:1033321302
Name:CARLSON, SANDRA REGINA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:REGINA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 S MAPLE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1545
Mailing Address - Country:US
Mailing Address - Phone:201-345-1855
Mailing Address - Fax:201-540-9935
Practice Address - Street 1:385 S MAPLE AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1545
Practice Address - Country:US
Practice Address - Phone:201-345-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08561400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine