MEDICARE: DR. SANDRA REGINA CARLSON M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	25MA08561400	NJ

General Provider Information

NPI Number	:	1033321302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA REGINA CARLSON M.D

Provider Business Mailing Address
First Line	:	385 S MAPLE AVE STE 101
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1545
Country	:	US
Telephone Number	:	201-345-1855
Fax Number	:	201-540-9935

Provider Business Practice Location Address
First Line	:	385 S MAPLE AVE STE 101
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1545
Country	:	US
Telephone Number	:	201-345-1855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	10/07/2015

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