Provider Demographics
NPI:1508178799
Name:CARLSON, JON BRANDON (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:BRANDON
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 1:2415 BARRETT AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3562
Mailing Address - Country:US
Mailing Address - Phone:317-213-2201
Mailing Address - Fax:
Practice Address - Street 1:2415 BARRETT AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3562
Practice Address - Country:US
Practice Address - Phone:317-213-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096967207X00000X
KY48167207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery