Provider Demographics
NPI:1528192150
Name:CARLSON, MARK LUTHER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LUTHER
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 1:1423 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-1917
Mailing Address - Country:US
Mailing Address - Phone:417-269-2273
Mailing Address - Fax:417-269-8851
Practice Address - Street 1:1423 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1917
Practice Address - Country:US
Practice Address - Phone:417-269-2273
Practice Address - Fax:417-269-8851
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101949207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE70209Medicare UPIN