Provider Demographics
NPI:1073515938
Name:CARLSON, RICHARD SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SCOTT
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MARQUETTE ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2509
Mailing Address - Country:US
Mailing Address - Phone:219-464-8223
Mailing Address - Fax:219-531-2356
Practice Address - Street 1:502 MARQUETTE ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2509
Practice Address - Country:US
Practice Address - Phone:219-464-8223
Practice Address - Fax:219-531-2356
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2151005OtherFIRST HEALTH
IL036059451Medicaid
IN200883420Medicaid
ILP00082449OtherMEDIARE RAILROAD
IN000000549868OtherANTHEM BC.BS
IL01635025OtherBCBS
ILU93328Medicare UPIN
IL204042Medicare PIN
IL036059451Medicaid