Provider Demographics
NPI:1164669404
Name:CARLSEN, JENS C (DO)
Entity Type:Individual
Prefix:
First Name:JENS
Middle Name:C
Last Name:CARLSEN
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 1:2525 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5317
Mailing Address - Country:US
Mailing Address - Phone:941-421-0756
Mailing Address - Fax:941-866-6809
Practice Address - Street 1:2525 HARBOR BLVD STE 301
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5342
Practice Address - Country:US
Practice Address - Phone:941-421-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10946208800000X
IL125047406208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002474100Medicaid
FLDI458ZMedicare PIN
FL002474100Medicaid