Basic Information
| Provider Information | |||||||||
| NPI: | 1255624896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANCHEZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | ALFONSO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ FL 13 | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
| FaxNumber: | 6468463283 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071024403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8622467940 | ||||||||
| FaxNumber: | 8622467941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB09378700 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 275285 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02845370 | 05 | NY | MEDICAID |