Provider Demographics
NPI:1740246735
Name:CARLSON JR, RICHARD ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ANDREW
Last Name:CARLSON JR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1491 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1234
Mailing Address - Country:US
Mailing Address - Phone:716-332-4476
Mailing Address - Fax:716-332-4479
Practice Address - Street 1:1491 SHERIDAN DR
Practice Address - Street 2:SHERIDAN MEDICAL GROUP
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14217-1234
Practice Address - Country:US
Practice Address - Phone:716-332-4476
Practice Address - Fax:716-332-4479
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183745207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01226122Medicaid
NY01226122Medicaid
NYDD4207Medicare PIN