Provider Demographics
NPI:1497700116
Name:CARLSON, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
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 1:520 SUPERIOR AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3637
Mailing Address - Country:US
Mailing Address - Phone:949-722-3300
Mailing Address - Fax:949-548-9465
Practice Address - Street 1:520 SUPERIOR AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3637
Practice Address - Country:US
Practice Address - Phone:949-722-3300
Practice Address - Fax:949-548-9465
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G27340Medicare UPIN