Provider Demographics
NPI:1851305064
Name:FEDERICO, CARMEN J (DO)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:J
Last Name:FEDERICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2911
Mailing Address - Country:US
Mailing Address - Phone:315-425-1431
Mailing Address - Fax:
Practice Address - Street 1:311 GREEN ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2911
Practice Address - Country:US
Practice Address - Phone:315-425-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203421-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01982172Medicaid
NY56676CMedicare ID - Type Unspecified
NYG55806Medicare UPIN