=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235253881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS TORRES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 664 SUFFOLK AVE
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-273-7645
-----------------------------------------------------
Fax | 631-273-4928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 664 SUFFOLK AVE
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-273-7645
-----------------------------------------------------
Fax | 631-273-4928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 119422
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------