Provider Demographics
NPI:1730239971
Name:CARVAJAL, CARLOS (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CARVAJAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E 95TH ST APT 4C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-4001
Mailing Address - Country:US
Mailing Address - Phone:510-499-4456
Mailing Address - Fax:
Practice Address - Street 1:1651 3RD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3679
Practice Address - Country:US
Practice Address - Phone:510-499-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 19139101YM0800X
NY2596952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health