Provider Demographics
NPI:1164402152
Name:CARLSON, DIANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15710 LINDBERGH LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8312
Mailing Address - Country:US
Mailing Address - Phone:631-871-4027
Mailing Address - Fax:
Practice Address - Street 1:3100 WESTON RD
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3602
Practice Address - Country:US
Practice Address - Phone:954-689-5173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207336207ZP0102X
FLME100065207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME100065OtherFLORIDA DEPT OF HEALTH
02Q901Medicare ID - Type Unspecified