Provider Demographics
NPI:1356440176
Name:CARLSON, VERNETTE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:VERNETTE
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
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 400
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:MI
Mailing Address - Zip Code:49887-0400
Mailing Address - Country:US
Mailing Address - Phone:906-753-4665
Mailing Address - Fax:906-753-4366
Practice Address - Street 1:S 926 US HWY 41
Practice Address - Street 2:
Practice Address - City:STEPHENSON
Practice Address - State:MI
Practice Address - Zip Code:49887
Practice Address - Country:US
Practice Address - Phone:906-753-4665
Practice Address - Fax:906-753-4366
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI048831207Q00000X
WI26935020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4654290Medicaid
MI0805500152OtherBCBS
0N95550Medicare PIN
MI4654290Medicaid