Provider Demographics
NPI:1235130329
Name:CARLSON, BRENT S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:M
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:PO BOX 411375
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1375
Mailing Address - Country:US
Mailing Address - Phone:816-781-9222
Mailing Address - Fax:816-781-9250
Practice Address - Street 1:2525 GLENN HENDREN DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9625
Practice Address - Country:US
Practice Address - Phone:816-792-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115625207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204703714Medicaid
MO35373016OtherBCBS MO
MO35373016OtherBCBS MO
MO204703714Medicaid