Provider Demographics
NPI:1043288673
Name:CARSON, CRAIG W (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:W
Last Name:CARSON
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 1:1701 RENAISSANCE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3084
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:405-844-0562
Practice Address - Street 1:1701 RENAISSANCE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3084
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17781207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE41316Medicare UPIN