Provider Demographics
NPI:1114087632
Name:CARLSON, DONALD J (DPM)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W ELM AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2715
Mailing Address - Country:US
Mailing Address - Phone:541-567-8750
Mailing Address - Fax:541-564-0498
Practice Address - Street 1:1050 W ELM AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2715
Practice Address - Country:US
Practice Address - Phone:541-567-8750
Practice Address - Fax:541-564-0498
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00233213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0880210001Medicare NSC
ORU32533Medicare UPIN