Provider Demographics
NPI:1598755522
Name:CARLSON, LISA R (MD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1605 SE DELAWARE AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-4594
Mailing Address - Country:US
Mailing Address - Phone:515-964-5555
Mailing Address - Fax:515-964-5505
Practice Address - Street 1:1605 SE DELAWARE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4594
Practice Address - Country:US
Practice Address - Phone:515-964-5555
Practice Address - Fax:515-964-5505
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IAIA 30072208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1113076Medicaid
IA1113076Medicaid