Provider Demographics
NPI:1639188972
Name:CARLSON, LAWRENCE DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:DOUGLAS
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 2120
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2120
Mailing Address - Country:US
Mailing Address - Phone:541-884-6233
Mailing Address - Fax:541-882-2840
Practice Address - Street 1:3001 DAGGETT AVE STE 101
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1126
Practice Address - Country:US
Practice Address - Phone:541-884-6233
Practice Address - Fax:541-880-2840
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62984207RC0000X, 207RI0011X
ORMD209372207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G629840OtherBLUE CROSS BLUE SHIELD
CA00G629840Medicaid
CA00G629840OtherBLUE CROSS BLUE SHIELD
CAG62984AMedicare ID - Type Unspecified