Provider Demographics
NPI:1609837368
Name:CARLSON, MARK O (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:O
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 1:1605 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1109
Mailing Address - Country:US
Mailing Address - Phone:712-234-1005
Mailing Address - Fax:712-234-0015
Practice Address - Street 1:1605 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1109
Practice Address - Country:US
Practice Address - Phone:712-234-1005
Practice Address - Fax:712-234-0015
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27247207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025457800Medicaid
SD6004143Medicaid
IAIB1201001OtherMEDICARE PTAN
IA2059956Medicaid
IAE16782Medicare UPIN