Healthcare Provider Details

I. General information

NPI: 1811006802
Provider Name (Legal Business Name): ANDREW CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 INDIAN RIVER RD SUITE B-1
ORANGE CT
06477-3649
US

IV. Provider business mailing address

240 INDIAN RIVER RD SUITE B-1
ORANGE CT
06477-3649
US

V. Phone/Fax

Practice location:
  • Phone: 203-795-4924
  • Fax: 203-799-1554
Mailing address:
  • Phone: 203-795-4924
  • Fax: 203-799-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number039862
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: