Provider Demographics
NPI:1548202450
Name:CARLSON, WAYNE A (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:A
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 1:2122 GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-9367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2122 GRANGE RD
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-9367
Practice Address - Country:US
Practice Address - Phone:269-471-5186
Practice Address - Fax:269-471-5086
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI064990207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWC064990OtherBC/BS
IN200981120Medicaid
MI4700197Medicaid
MI4707975Medicaid
MIM60660298Medicare PIN
MI4707975Medicaid
MI4700197Medicaid