Provider Demographics
NPI:1710942859
Name:CARLSON, DAVID EUGENE JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EUGENE
Last Name:CARLSON
Suffix:JR
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 1:6255 SHERIDAN DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4836
Mailing Address - Country:US
Mailing Address - Phone:716-857-8666
Mailing Address - Fax:716-630-1054
Practice Address - Street 1:277 DIVISION ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-4667
Practice Address - Country:US
Practice Address - Phone:716-694-3541
Practice Address - Fax:716-694-3543
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190642207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0661027Medicaid
NY0661027Medicaid
NY14363CMedicare ID - Type UnspecifiedMEDICARE