Provider Demographics
NPI:1073778643
Name:DICARLO, MARY
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:DICARLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 LANG AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4495
Mailing Address - Country:US
Mailing Address - Phone:505-842-8171
Mailing Address - Fax:505-246-0687
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:505-246-0687
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine