Provider Demographics
NPI:1144211608
Name:CARLSON, STEPHEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1011 REED AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-2002
Mailing Address - Country:US
Mailing Address - Phone:610-374-4401
Mailing Address - Fax:610-374-7140
Practice Address - Street 1:1011 REED AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-2002
Practice Address - Country:US
Practice Address - Phone:610-374-4401
Practice Address - Fax:610-374-7140
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD024737E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008608710005Medicaid
PAA46446Medicare UPIN
PA063135ES4Medicare PIN