Provider Demographics
NPI:1023008398
Name:CARLSON, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:CARLSON
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 1:1905 S LAKELINE BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4660
Mailing Address - Country:US
Mailing Address - Phone:512-553-1921
Mailing Address - Fax:
Practice Address - Street 1:1905 S LAKELINE BLVD STE 4
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:512-553-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2258207QG0300X, 207RH0003X, 207R00000X
NE21230207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02601OtherBCBS
KS200269020AMedicaid
NE3600078OtherUHC
NE6452OtherMIDLANDS CHOICE
NE91186278513Medicaid
NE02601OtherBCBS
NE6452OtherMIDLANDS CHOICE
NE272163Medicare PIN