Provider Demographics
NPI:1609027689
Name:CARLSON, JEFFREY LYNN (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2404
Mailing Address - Country:US
Mailing Address - Phone:937-492-1211
Mailing Address - Fax:937-492-6557
Practice Address - Street 1:1000 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-2404
Practice Address - Country:US
Practice Address - Phone:937-492-1211
Practice Address - Fax:937-492-6557
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003576213ES0103X
UT7054576-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3133424Medicaid
OH4316922Medicare PIN
OH3133424Medicaid
OH4316921Medicare PIN