Provider Demographics
NPI:1326072869
Name:CARSON, JOHN BERTRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BERTRAM
Last Name:CARSON
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 660969
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0969
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7127
Practice Address - Country:US
Practice Address - Phone:928-336-7100
Practice Address - Fax:928-336-7508
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15263207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ245531Medicaid
AZXPY191679Medicaid
AZZWDBYNMedicare PIN
AZ23418Medicare PIN
AZE64885Medicare UPIN
AZ245531Medicaid