Provider Demographics
NPI:1801861513
Name:CARLSON, RAYMOND J (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1664
Mailing Address - Country:US
Mailing Address - Phone:315-470-7409
Mailing Address - Fax:315-475-2357
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1664
Practice Address - Country:US
Practice Address - Phone:315-470-7409
Practice Address - Fax:315-475-2357
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY153692207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01013501Medicaid
B82546Medicare UPIN
BB1078Medicare ID - Type Unspecified