Provider Demographics
NPI:1912043761
Name:BURLEY, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:BURLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1984
Practice Address - Country:US
Practice Address - Phone:315-764-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004732156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00673327Medicaid
NY00673327Medicaid