Provider Demographics
NPI:1093749640
Name:CARLSON, KEITH CAMERON (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:CAMERON
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 NE 10TH ST
Mailing Address - Street 2:BELLEVUE MEDICAL CENTER
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-502-3000
Mailing Address - Fax:425-502-3589
Practice Address - Street 1:11511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8578
Practice Address - Country:US
Practice Address - Phone:425-502-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60650552207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G501320OtherMEDICAL PPIN #
CAWG50132BMedicare ID - Type UnspecifiedPPIN #
CA00G501320OtherMEDICAL PPIN #