Provider Demographics
NPI:1194883793
Name:BORIS, CARL (DO)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:BORIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1203
Mailing Address - Country:US
Mailing Address - Phone:516-795-2626
Mailing Address - Fax:516-799-7451
Practice Address - Street 1:99 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1203
Practice Address - Country:US
Practice Address - Phone:516-541-9700
Practice Address - Fax:516-798-1086
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
201285536OtherEMPIRE
5491B1OtherBLUE CROSS BLUE SHIELD
5C4402OtherHEALTH NET
AP624OtherOXFORD
4115108OtherAETNA
089458OtherHIP
5061OtherVYTRA
5996232OtherGHI
P00230863OtherRR MCR
201285536OtherMAGNACARE
785722OtherCIGNA
NY00404884Medicaid
201285536OtherUNITED HEALTHCARE
5996232OtherGHI
089458OtherHIP