Provider Demographics
NPI:1437136371
Name:CARLSON, JON PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:PAUL
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 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:952-993-6547
Mailing Address - Fax:952-993-6518
Practice Address - Street 1:6600 EXCELSIOR BLVD. SUITE 131
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN728585000Medicaid
MN110000421Medicare ID - Type Unspecified
MN728585000Medicaid