Provider Demographics
NPI:1114036738
Name:CARLSON, EDWARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
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 1:433 OAKLAND LN
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1659
Mailing Address - Country:US
Mailing Address - Phone:262-723-4455
Mailing Address - Fax:
Practice Address - Street 1:433 OAKLAND LN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1659
Practice Address - Country:US
Practice Address - Phone:262-723-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0161173024 1Medicaid
WI31204000Medicaid
WI54176 0305Medicare ID - Type Unspecified
WI31204000Medicaid