Provider Demographics
NPI:1114958055
Name:CARLSON, ALAN B (DPM)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:B
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 1:760 E PUSCH VIEW LN
Mailing Address - Street 2:SUTIE 130
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-9235
Mailing Address - Country:US
Mailing Address - Phone:520-877-3668
Mailing Address - Fax:520-979-0125
Practice Address - Street 1:760 E PUSCH VIEW LN
Practice Address - Street 2:SUITE 130
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85737-9235
Practice Address - Country:US
Practice Address - Phone:520-877-3668
Practice Address - Fax:520-797-0125
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN449213E00000X
AZ694213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103291OtherUCARE - ROSEVILLE
MN103295OtherUCARE HIGHLAND
AZ487052Medicaid
MN504025600Medicaid
MN64599CAOtherBCBS
MN504025600Medicaid
MN103291OtherUCARE - ROSEVILLE
MN64599CAOtherBCBS
AZ487052Medicaid