Provider Demographics
NPI:1518029347
Name:CARLSON, JEFFREY R (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
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 1:250 NAT TURNER BLVD S
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2899
Mailing Address - Country:US
Mailing Address - Phone:757-596-1900
Mailing Address - Fax:866-420-0168
Practice Address - Street 1:250 NAT TURNER BLVD S
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2899
Practice Address - Country:US
Practice Address - Phone:757-596-1900
Practice Address - Fax:866-420-0168
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059179207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6407188Medicaid
208171OtherANTHEM BC
200001014Medicare ID - Type Unspecified
G64569Medicare UPIN