Provider Demographics
NPI:1164544045
Name:CARLSON, CHESTER L (DO)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:L
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 1:5212 VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8104
Mailing Address - Country:US
Mailing Address - Phone:479-657-6888
Mailing Address - Fax:
Practice Address - Street 1:5212 VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8104
Practice Address - Country:US
Practice Address - Phone:479-657-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5307207P00000X, 208D00000X
ARE5307208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166986003Medicaid
AR5H348OtherARKANSAS BLUE CROSS
AR5H035Medicare PIN