Provider Demographics
NPI:1083835375
Name:CARSON, DOUGLAS LEE (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:CARSON
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 1:109 SPRINGDALE DR
Mailing Address - Street 2:SUITE #7
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-6014
Mailing Address - Country:US
Mailing Address - Phone:859-296-4508
Mailing Address - Fax:859-296-4483
Practice Address - Street 1:109 SPRINGDALE DR
Practice Address - Street 2:SUITE #7
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6014
Practice Address - Country:US
Practice Address - Phone:859-296-4508
Practice Address - Fax:859-296-4483
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1263111N00000X
FL2827111N00000X
KY3686R111N00000X
TN198111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
6042301Medicare ID - Type Unspecified
T54442Medicare UPIN