Provider Demographics
NPI:1275680068
Name:CARLSON, STEPHAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:MICHAEL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 BROOKDALE PLZ STE 666
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-3198
Mailing Address - Country:US
Mailing Address - Phone:718-240-5811
Mailing Address - Fax:718-240-5805
Practice Address - Street 1:ONE BROOKDALE PLAZA
Practice Address - Street 2:DEPT. OF PSYCHIATRY
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3198
Practice Address - Country:US
Practice Address - Phone:718-240-6059
Practice Address - Fax:718-240-5986
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24365612084F0202X
NY2436562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03013141Medicaid
NYA400047834Medicare PIN