Provider Demographics
NPI:1093030975
Name:CONWELL B. CARTER, M.D., INC.
Entity Type:Organization
Organization Name:CONWELL B. CARTER, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CONWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-276-6978
Mailing Address - Street 1:400 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3250
Mailing Address - Fax:203-503-3254
Practice Address - Street 1:400 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3250
Practice Address - Fax:203-503-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23247207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A232470Medicaid
CT004235900Medicaid
CAA23247Medicare PIN