Provider Demographics
NPI:1639125651
Name:MAGNUSSEN, CARL RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RICHARD
Last Name:MAGNUSSEN
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:BOX 57
Mailing Address - Street 2:1000 S AVE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2733
Mailing Address - Country:US
Mailing Address - Phone:585-341-6867
Mailing Address - Fax:585-341-8205
Practice Address - Street 1:1000 S AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2733
Practice Address - Country:US
Practice Address - Phone:585-341-6867
Practice Address - Fax:585-341-8205
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122394207R00000X, 207RA0201X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00456271Medicaid
NY1007058YOtherPREFERRED CARE
NY10242BMedicare ID - Type Unspecified
NY1007058YOtherPREFERRED CARE