Provider Demographics
NPI:1518412238
Name:CARLSON MEDICAL, PLLC
Entity Type:Organization
Organization Name:CARLSON MEDICAL, PLLC
Other - Org Name:WISE WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-395-3577
Mailing Address - Street 1:486 TOWN PLAZA AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-5141
Mailing Address - Country:US
Mailing Address - Phone:904-395-3577
Mailing Address - Fax:904-834-7821
Practice Address - Street 1:486 TOWN PLAZA AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5141
Practice Address - Country:US
Practice Address - Phone:904-395-3577
Practice Address - Fax:904-834-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112115261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH93848Medicare UPIN