Provider Demographics
NPI:1598854358
Name:CARLSON, ELMER THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:THOMAS
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 1:4880 N HIGHWAY 19A
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2018
Mailing Address - Country:US
Mailing Address - Phone:352-589-8111
Mailing Address - Fax:352-589-8495
Practice Address - Street 1:4880 N HIGHWAY 19A
Practice Address - Street 2:SUITE 200
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2018
Practice Address - Country:US
Practice Address - Phone:352-589-8111
Practice Address - Fax:352-589-8495
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 201142080A0000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Not Answered2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4471200OtherAETNA PROVIDER #
FL203150OtherHEALTHEASE PROVIDER #
FL35124OtherBLUECROSS/BLUESHIELD
FL108915Medicare ID - Type Unspecified
FLD82427Medicare UPIN