Provider Demographics
NPI:1073885166
Name:CARLSON, JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10260 SW GREENBURG RD STE 414
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5500
Mailing Address - Country:US
Mailing Address - Phone:503-597-8841
Mailing Address - Fax:503-213-5860
Practice Address - Street 1:10260 SW GREENBURG RD STE 414
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5500
Practice Address - Country:US
Practice Address - Phone:503-597-8841
Practice Address - Fax:503-213-5860
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500725966Medicaid