Provider Demographics
NPI:1508896911
Name:CARLSON, MARK VAUGHN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VAUGHN
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 1:336 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVID CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68632-2116
Mailing Address - Country:US
Mailing Address - Phone:402-367-3193
Mailing Address - Fax:402-367-3261
Practice Address - Street 1:336 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DAVID CITY
Practice Address - State:NE
Practice Address - Zip Code:68632-2116
Practice Address - Country:US
Practice Address - Phone:402-367-3193
Practice Address - Fax:402-367-3261
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE097651Medicare ID - Type Unspecified
NEF43978Medicare UPIN
NE080079182Medicare PIN
NE261798Medicare ID - Type Unspecified