Provider Demographics
NPI:1003121849
Name:CARLSTON, CORY VERNON (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:VERNON
Last Name:CARLSTON
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 1:10000 SE MAIN ST STE 224
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2469
Mailing Address - Country:US
Mailing Address - Phone:503-261-6961
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST STE 224
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2469
Practice Address - Country:US
Practice Address - Phone:503-261-6961
Practice Address - Fax:503-261-6959
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD182611207XS0106X, 207XS0106X
CAA111936207X00000X
MN61265207X00000X
NMMD2014-0487207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery