Provider Demographics
NPI:1760449615
Name:CARLSON, CYNTHIA (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2121
Mailing Address - Country:US
Mailing Address - Phone:631-298-4479
Mailing Address - Fax:631-591-3047
Practice Address - Street 1:7905 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952
Practice Address - Country:US
Practice Address - Phone:631-298-2030
Practice Address - Fax:631-298-8915
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY650582Medicare PIN
NYG32208Medicare UPIN