Provider Demographics
NPI:1568543783
Name:CARLSON, HANSEN, KWON-HONG, MDS
Entity Type:Organization
Organization Name:CARLSON, HANSEN, KWON-HONG, MDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-549-9900
Mailing Address - Street 1:5101 MESA DR
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-7858
Mailing Address - Country:US
Mailing Address - Phone:209-848-8903
Mailing Address - Fax:
Practice Address - Street 1:1213 COFFEE RD
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4229
Practice Address - Country:US
Practice Address - Phone:209-549-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ250725ZMedicare ID - Type Unspecified