Provider Demographics
NPI:1982960969
Name:CARLYLE, BRENT EVANS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:EVANS
Last Name:CARLYLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 GENESEE STREET, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421
Mailing Address - Country:US
Mailing Address - Phone:315-363-8862
Mailing Address - Fax:315-363-3326
Practice Address - Street 1:357 GENESEE ST STE 1
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2658
Practice Address - Country:US
Practice Address - Phone:315-363-8862
Practice Address - Fax:315-363-3326
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288249208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0122476Medicaid