Provider Demographics
NPI:1740447051
Name:GEORGE, CAROLYN SUE (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12651 W SUNRISE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-0906
Mailing Address - Country:US
Mailing Address - Phone:954-361-5202
Mailing Address - Fax:954-488-7741
Practice Address - Street 1:12651 W SUNRISE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0906
Practice Address - Country:US
Practice Address - Phone:954-361-5202
Practice Address - Fax:954-448-7741
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91928207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G67168Medicare UPIN