=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942650189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUKE THOMAS CARLSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2016
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1650 GRAND CONCOURSE BRONX-LEBANON HOSPITAL CENTER
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-7606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-960-1417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 W 149TH ST APT. 53
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10031-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-406-2234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | 301752
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------