Provider Demographics
NPI:1124007521
Name:CARLSON, CLARENCE ROY JR (DO)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:ROY
Last Name:CARLSON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 OAK ST
Mailing Address - Street 2:APT. 7
Mailing Address - City:EMMONS
Mailing Address - State:MN
Mailing Address - Zip Code:56029-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34377207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN458507100Medicaid
MN458507100Medicaid
MN930002258Medicare ID - Type Unspecified