Provider Demographics
NPI:1659317097
Name:JENSON, CARL RYDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RYDELL
Last Name:JENSON
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 1:1775 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2198
Mailing Address - Country:US
Mailing Address - Phone:541-269-8111
Mailing Address - Fax:541-269-8517
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2198
Practice Address - Country:US
Practice Address - Phone:541-269-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN607802085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400319941Medicare PIN
OR287809Medicaid
ORD25989Medicare UPIN