Provider Demographics
NPI:1417068776
Name:CARSON, DWIGHT K (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:K
Last Name:CARSON
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 1:15201 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2803
Mailing Address - Country:US
Mailing Address - Phone:216-541-5600
Mailing Address - Fax:
Practice Address - Street 1:15201 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-2803
Practice Address - Country:US
Practice Address - Phone:216-541-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538501Medicaid
OHA15610Medicare UPIN
OH0538501Medicaid