Provider Demographics
NPI:1114077468
Name:CARLSON, RAY LYNN (MD)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:LYNN
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:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0240
Mailing Address - Country:US
Mailing Address - Phone:907-283-9118
Mailing Address - Fax:907-283-5341
Practice Address - Street 1:10543 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7812
Practice Address - Country:US
Practice Address - Phone:907-283-9118
Practice Address - Fax:907-283-5341
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK2778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2778Medicaid
AKMD2778Medicaid