Provider Demographics
NPI:1194835181
Name:CARLSON, JAY W (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:W
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:STE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-3554
Practice Address - Fax:417-820-3587
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJC015918207VX0201X
IA40382086X0206X, 207VX0201X
MO2011006588207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194835181Medicaid
AR187019003Medicaid
OK200454170AMedicaid
MO1194835181Medicaid