Provider Demographics
NPI:1477532810
Name:CARLSON, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
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:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81215-0310
Mailing Address - Country:US
Mailing Address - Phone:719-275-0685
Mailing Address - Fax:719-275-0690
Practice Address - Street 1:933 SELL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4900
Practice Address - Country:US
Practice Address - Phone:719-275-0685
Practice Address - Fax:719-275-0690
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30252207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
159056900OtherUS DEPT OF LABOR
5502AMPR005587OtherANTHEM BCBS NASCO BLUE CA
29405OtherANTHEM BCBS
COP00262002OtherRAILROAD MEDICARE
CO01302520Medicaid
5502AMPR005587OtherANTHEM BCBS NASCO BLUE CA
CO4400320001Medicare PIN
COP00262002OtherRAILROAD MEDICARE
CO4400320001Medicare NSC
29405OtherANTHEM BCBS