Provider Demographics
NPI:1467542241
Name:CARLSON, JOHN D (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2170 HIGHWAY 51 S STE 6
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1108
Mailing Address - Country:US
Mailing Address - Phone:662-449-1384
Mailing Address - Fax:662-449-1385
Practice Address - Street 1:2170 HIGHWAY 51 S STE 6
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1108
Practice Address - Country:US
Practice Address - Phone:662-449-1384
Practice Address - Fax:662-449-1385
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7068456OtherAETNA PIN
MS00880114Medicaid
TN4053594OtherBCBS OF TN
MSP00697422OtherRETIRED RAILROAD MEDICARE PTAN
MSP00697422OtherRETIRED RAILROAD MEDICARE PTAN
MSU92844Medicare UPIN
MS00880114Medicaid