Provider Demographics
NPI:1790386399
Name:ELLISTON, CARL (DABR)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:ELLISTON
Suffix:
Gender:M
Credentials:DABR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MANHASSET AVE
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2219
Mailing Address - Country:US
Mailing Address - Phone:917-501-2367
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0005072085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics