Provider Demographics
NPI:1073603775
Name:CARLSON, MITCHELL R (PT)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7581 9TH ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6635
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:
Practice Address - Street 1:5959 BAKER RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5900
Practice Address - Country:US
Practice Address - Phone:651-348-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014144225100000X
MN2899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010114144OtherBLUE CHOICE
NY601318000OtherOWCP
NY7735556OtherAETNA
NY020114144OtherBCBS
NY145851FTOtherPREFERRED CARE
NYP00170719Medicare ID - Type UnspecifiedMEDICARE RAILROAD
NYRA2916Medicare ID - Type UnspecifiedMEDICARE
NYBA0262Medicare UPIN