Provider Demographics
NPI:1578632899
Name:CANAVIRE WEBER, CARLA (DO)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:
Last Name:CANAVIRE WEBER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7952
Mailing Address - Country:US
Mailing Address - Phone:631-328-5560
Mailing Address - Fax:631-328-5559
Practice Address - Street 1:1745 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7952
Practice Address - Country:US
Practice Address - Phone:631-328-5560
Practice Address - Fax:631-328-5559
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2108831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933499Medicaid
NY924761Medicare ID - Type Unspecified
G91319Medicare UPIN
NY01933499Medicaid