Provider Demographics
NPI:1619989787
Name:CARLSON, RICHARD H (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 FLETCHER PKWY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2107
Mailing Address - Country:US
Mailing Address - Phone:619-463-9975
Mailing Address - Fax:
Practice Address - Street 1:2508 FLETCHER PKWY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2107
Practice Address - Country:US
Practice Address - Phone:619-463-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6626T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066260Medicaid
CASD0066260Medicaid