Provider Demographics
NPI:1518031475
Name:CARLSON, JAMES EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:6831 W 133RD AVE
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-8989
Practice Address - Country:US
Practice Address - Phone:219-374-5970
Practice Address - Fax:219-374-7505
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004028A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201079400Medicaid
NY01826791Medicaid
INM400075217Medicare PIN
IN201079400Medicaid
NY01826791Medicaid