Provider Demographics
NPI:1598973083
Name:DAVIS, CARMEN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:D
Other - Last Name:LAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:1 WORLD 'S FAIR DR.
Practice Address - Street 2:SUITE 2400
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-235-7688
Practice Address - Fax:732-235-6568
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00161500207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ112183BDKMedicare PIN