Provider Demographics
NPI:1174509137
Name:CARLSON, GEORGINA LENORE DIXON (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGINA
Middle Name:LENORE DIXON
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 1:1500 CURVE CREST BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6040
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:651-275-3325
Practice Address - Street 1:1500 CURVE CREST BOULEVARD
Practice Address - Street 2:STILLWATER MEDICAL GROUP
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-275-3325
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32108100Medicaid
MN885563300Medicaid
MN885563300Medicaid
MN080013983Medicare PIN
P00197375Medicare PIN