Healthcare Provider Details

I. General information

NPI: 1649912718
Provider Name (Legal Business Name): MADISON ELIZABETH CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

462 GRIDER ST
BUFFALO NY
14215-3021
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-4221
  • Fax:
Mailing address:
  • Phone: 716-898-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number342418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: