Provider Demographics
NPI:1477103232
Name:CARSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CARSON
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:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:NORMANDY BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08739-0229
Mailing Address - Country:US
Mailing Address - Phone:973-951-6287
Mailing Address - Fax:
Practice Address - Street 1:229 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:NORMANDY BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08739-0229
Practice Address - Country:US
Practice Address - Phone:973-951-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJC06845216305494172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver