Provider Demographics
NPI:1386672947
Name:CARLSON, RODNEY LYNDEN (DPM)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:LYNDEN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 CHEATHAM WAY
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305
Mailing Address - Country:US
Mailing Address - Phone:937-848-6676
Mailing Address - Fax:937-233-5937
Practice Address - Street 1:550 HALLMARK DR
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-8648
Practice Address - Country:US
Practice Address - Phone:937-848-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003212213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2223249Medicaid
OHP00976480Medicare PIN
OH2223249Medicaid
OHCA4031768Medicare PIN