Provider Demographics
NPI:1528571627
Name:CARLSON PODIATRIC CARE PLLC
Entity Type:Organization
Organization Name:CARLSON PODIATRIC CARE PLLC
Other - Org Name:DR MARY CARLSON FOOT AND ANKLE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LEE
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 STE E
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1161
Mailing Address - Country:US
Mailing Address - Phone:516-248-8188
Mailing Address - Fax:516-279-4921
Practice Address - Street 1:637 WILLIS AVE STE E
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1161
Practice Address - Country:US
Practice Address - Phone:516-248-8188
Practice Address - Fax:516-279-4921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARLSON PODIATRIC CARE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005090213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP3317984OtherOXFORD
NY2864001OtherEMPIRE BC/BS