Provider Demographics
NPI:1376004044
Name:CARSON, MALLORY PAIGE (DO)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:PAIGE
Last Name:CARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9314 244TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3913
Mailing Address - Country:US
Mailing Address - Phone:516-509-4634
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK CHILDREN'S DEPARTMENT OF PEDIATRICS
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2020
Practice Address - Fax:631-444-2894
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics