Provider Demographics
NPI:1083147417
Name:CARLSON, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:925-295-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR205573207P00000X
390200000X
CA182703207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty