Provider Demographics
NPI:1306831516
Name:CARLSEN, GREGORY H (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:CARLSEN
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:204 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1804
Practice Address - Country:US
Practice Address - Phone:859-236-9819
Practice Address - Fax:859-236-2192
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY326062085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1135712OtherPASSPORT HEALTH PROV. #
KY1135712OtherPASSPORT MED ADV #
KY000000306671OtherANTHEM BCBS PROV. #
KY50001834OtherPASSPORT HEALTH GRP #
FL1206474OtherGATEWAY HEALTH
KY1859601Medicaid
KY000000476307OtherANTHEM BCBS PROV. #
KYP00113978OtherRAILROAD MCARE #
KY564019OtherSTERLING HEALTH
KY564019OtherSTERLING HEALTH
KY1135712OtherPASSPORT HEALTH PROV. #
KY1859601Medicaid