Provider Demographics
NPI:1851494165
Name:JENSIS- CARLSON, MARY L (DPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:JENSIS- CARLSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:7401 SHORE RD
Mailing Address - Street 2:APT 1H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1953
Mailing Address - Country:US
Mailing Address - Phone:718-833-0550
Mailing Address - Fax:
Practice Address - Street 1:637 WILLIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1154
Practice Address - Country:US
Practice Address - Phone:516-248-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005090213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP60891Medicare PIN
NYU45386Medicare UPIN