Provider Demographics
NPI:1144200916
Name:CARLSON, JOEL ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:ANDREW
Last Name:CARLSON
Suffix:
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 1:777 HOSPITAL WAY
Mailing Address - Street 2:BLDG A SUITE 300
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5176
Mailing Address - Country:US
Mailing Address - Phone:208-233-1720
Mailing Address - Fax:208-239-3403
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:BLDG A SUITE 300
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5176
Practice Address - Country:US
Practice Address - Phone:208-233-1720
Practice Address - Fax:208-239-3403
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3140207V00000X
IDO-0407207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS6109OtherBLUE CROSS
ID000010156981OtherREGENCE-BLUE SHIELD
ID807508700Medicaid
ID546490OtherDESERET MUTUAL
IDP00355281OtherRAILROAD MEDICARE
ID000010156981OtherREGENCE-BLUE SHIELD
ID546490OtherDESERET MUTUAL