Provider Demographics
NPI:1336303452
Name:KENNETH P. CARLSON, M.D.
Entity Type:Organization
Organization Name:KENNETH P. CARLSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-468-3911
Mailing Address - Street 1:3125 MATLOCK RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2920
Mailing Address - Country:US
Mailing Address - Phone:817-468-3911
Mailing Address - Fax:817-468-0374
Practice Address - Street 1:3125 MATLOCK RD
Practice Address - Street 2:SUITE 108
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2920
Practice Address - Country:US
Practice Address - Phone:817-468-3911
Practice Address - Fax:817-468-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCE9141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty