Provider Demographics
NPI:1386669489
Name:CARLSON, CARL JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JEFFREY
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 1:2333 MOWRY AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1700
Mailing Address - Country:US
Mailing Address - Phone:510-792-2012
Mailing Address - Fax:510-792-7986
Practice Address - Street 1:2333 MOWRY AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1700
Practice Address - Country:US
Practice Address - Phone:510-792-2012
Practice Address - Fax:510-792-7986
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29295207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA060006330OtherRAILROAD MEDICARE
CAA44008OtherCOMMERCIAL
CA00G292950Medicaid
CA00G292950OtherBLUECROSS AND BLUESHIELD
CAA44008Medicare UPIN
CA060006330OtherRAILROAD MEDICARE