Provider Demographics
NPI:1356308787
Name:CARSON, MARY F (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:CARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5123
Practice Address - Country:US
Practice Address - Phone:617-859-5250
Practice Address - Fax:617-859-5250
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220644207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ27834OtherBLUE CROSS
MAAA15176OtherHARVARD PILGRIM
MA465568OtherTUFTS HEALTH PLAN
MA2081059Medicaid
MA0033055OtherNEIGHBORHOOD HEALTH PLAN
MAI15997Medicare UPIN
MA2081059Medicaid