Provider Demographics
NPI:1508893512
Name:CARLSON, CARL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JOSEPH
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:JOSEPH
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13624 W. CAMINO DEL SOL
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-3405
Mailing Address - Country:US
Mailing Address - Phone:623-546-0203
Mailing Address - Fax:623-546-5841
Practice Address - Street 1:13624 W CAMINO DEL SOL
Practice Address - Street 2:SUITE 150
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-3405
Practice Address - Country:US
Practice Address - Phone:623-546-0203
Practice Address - Fax:623-546-5841
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17742207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD86739Medicare UPIN
AZMD17742Medicare ID - Type UnspecifiedMEDICARE ID