Provider Demographics
NPI:1114032109
Name:DENNISON, CARL F
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:F
Last Name:DENNISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4347
Mailing Address - Country:US
Mailing Address - Phone:954-776-4981
Mailing Address - Fax:954-776-0146
Practice Address - Street 1:3035 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4347
Practice Address - Country:US
Practice Address - Phone:954-776-4981
Practice Address - Fax:954-776-0146
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62956207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3752810000Medicaid
FL23977ZMedicare ID - Type Unspecified
FL3752810000Medicaid