Provider Demographics
NPI:1508002783
Name:MARY JENSIS-CARLSON D P M
Entity Type:Organization
Organization Name:MARY JENSIS-CARLSON D P M
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JENSIS-CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-248-8188
Mailing Address - Street 1:637 WILLIS AVE
Mailing Address - Street 2:STE D.
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1154
Mailing Address - Country:US
Mailing Address - Phone:516-248-8188
Mailing Address - Fax:516-279-4610
Practice Address - Street 1:637 WILLIS AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1154
Practice Address - Country:US
Practice Address - Phone:516-248-8188
Practice Address - Fax:516-279-4610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005090213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6159240001Medicare NSC