Provider Demographics
NPI:1336294438
Name:CARLSON, DOUGLAS L (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
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 1:8905 W LINCOLN AVE
Mailing Address - Street 2:SUITE # 515
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2468
Mailing Address - Country:US
Mailing Address - Phone:414-328-8650
Mailing Address - Fax:414-328-8660
Practice Address - Street 1:8905 W LINCOLN AVE
Practice Address - Street 2:SUITE # 515
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2468
Practice Address - Country:US
Practice Address - Phone:414-328-8650
Practice Address - Fax:414-328-8660
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29192207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31956900Medicaid
WI023050194Medicare PIN