Provider Demographics
NPI:1578546081
Name:CARLSON, KIMBERLY S (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-318-1745
Mailing Address - Fax:520-318-1748
Practice Address - Street 1:3987 E PARADISE FALLS DR STE 118
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6693
Practice Address - Country:US
Practice Address - Phone:520-318-1745
Practice Address - Fax:520-318-1748
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ495649Medicaid
103702Medicare ID - Type Unspecified
AZH18996Medicare UPIN