Provider Demographics
NPI:1053847186
Name:CARLSON-DEXTER, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:CARLSON-DEXTER
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:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:2909 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3100
Practice Address - Country:US
Practice Address - Phone:779-696-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-070084390200000X
IL036151529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program