Provider Demographics
NPI:1790946655
Name:PENROSE, CAROLIN T (MD)
Entity Type:Individual
Prefix:
First Name:CAROLIN
Middle Name:T
Last Name:PENROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLIN
Other - Middle Name:
Other - Last Name:SUAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1110 SOUTH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3411
Mailing Address - Country:US
Mailing Address - Phone:917-830-1415
Mailing Address - Fax:917-830-1418
Practice Address - Street 1:1110 SOUTH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3411
Practice Address - Country:US
Practice Address - Phone:917-830-1415
Practice Address - Fax:917-830-1418
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245597207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology