Provider Demographics
NPI:1578724787
Name:CARSON, JOHN MANNING (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MANNING
Last Name:CARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OLD COUNTRY RD STE 135
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4237
Mailing Address - Country:US
Mailing Address - Phone:516-663-2169
Mailing Address - Fax:516-663-2179
Practice Address - Street 1:200 OLD COUNTRY RD STE 135
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4237
Practice Address - Country:US
Practice Address - Phone:516-663-2169
Practice Address - Fax:516-663-2179
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291345207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO023865OtherKAISER COMMERCIAL NUMBER
CO80284272Medicaid
CO80284272Medicaid