Provider Demographics
NPI:1598967119
Name:CARLSON, GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
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:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-0888
Mailing Address - Country:US
Mailing Address - Phone:808-879-8716
Mailing Address - Fax:808-879-0500
Practice Address - Street 1:645 LANIOLU PL
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-9343
Practice Address - Country:US
Practice Address - Phone:808-879-6121
Practice Address - Fax:808-879-0500
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD3884207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIY051675Medicaid
HIY051675Medicaid
HI0000BDHDRMedicare ID - Type Unspecified