Provider Demographics
NPI:1609916063
Name:CARLSON, BRENDT D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDT
Middle Name:D
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 1:846 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076
Mailing Address - Country:US
Mailing Address - Phone:831-761-7225
Mailing Address - Fax:831-761-1178
Practice Address - Street 1:846 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-761-7225
Practice Address - Fax:831-761-1178
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29486Medicare UPIN
CA1877591587Medicare ID - Type Unspecified