Provider Demographics
NPI:1154478113
Name:CARLSON, DAVID ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-9534
Mailing Address - Country:US
Mailing Address - Phone:585-924-1550
Mailing Address - Fax:585-924-1589
Practice Address - Street 1:1160 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9534
Practice Address - Country:US
Practice Address - Phone:585-924-1550
Practice Address - Fax:585-924-1589
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1621652083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF22086Medicare UPIN