Provider Demographics
NPI:1720054141
Name:CARLSSON, WAYNE ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
Last Name:CARLSSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1723
Mailing Address - Country:US
Mailing Address - Phone:716-763-0949
Mailing Address - Fax:716-763-0952
Practice Address - Street 1:60 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1723
Practice Address - Country:US
Practice Address - Phone:716-763-0949
Practice Address - Fax:716-763-0952
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010927111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC10927-4BOtherWORKER'S COMPENSATION
NY000270363-01OtherUNIVERA
NY000293039003OtherBLUECROSS BLUESHIELD
NY8812768OtherINDEPENDENT HEALTH
NYIA0593Medicare ID - Type Unspecified