Provider Demographics
NPI:1649231192
Name:CARLSON, DORI M (OD)
Entity Type:Individual
Prefix:DR
First Name:DORI
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:F
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:PO BOX O
Mailing Address - Street 2:121 BRIGGS AVE N
Mailing Address - City:PARK RIVER
Mailing Address - State:ND
Mailing Address - Zip Code:58270-0714
Mailing Address - Country:US
Mailing Address - Phone:701-284-7330
Mailing Address - Fax:701-284-7332
Practice Address - Street 1:121 BRIGGS AVE N
Practice Address - Street 2:
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270-0714
Practice Address - Country:US
Practice Address - Phone:701-284-7330
Practice Address - Fax:701-284-7332
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60418Medicaid
NDU13726Medicare UPIN
ND10364Medicare PIN