Provider Demographics
NPI:1518953306
Name:CARLSON, KENT ARTHUR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:ARTHUR
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 1:3401 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3477
Mailing Address - Country:US
Mailing Address - Phone:320-759-2020
Mailing Address - Fax:320-759-2424
Practice Address - Street 1:3401 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3477
Practice Address - Country:US
Practice Address - Phone:320-759-2020
Practice Address - Fax:320-759-2424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
MN31849207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95905Medicare UPIN