Provider Demographics
NPI:1811980873
Name:CARLETON, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CARLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 RED MILLS RD
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-3220
Mailing Address - Country:US
Mailing Address - Phone:845-744-9105
Mailing Address - Fax:845-744-9107
Practice Address - Street 1:600 STONY BROOK CT
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-6524
Practice Address - Country:US
Practice Address - Phone:845-391-8557
Practice Address - Fax:845-608-8270
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY128487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00874864Medicaid
NY88A991Medicare PIN
B87345Medicare UPIN