Provider Demographics
NPI:1679548879
Name:CARLSON, KEITH HAROLD (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:HAROLD
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 1:710 E 24TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3810
Mailing Address - Country:US
Mailing Address - Phone:612-775-8009
Mailing Address - Fax:612-775-8005
Practice Address - Street 1:710 E 24TH ST STE 205
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3810
Practice Address - Country:US
Practice Address - Phone:612-775-8009
Practice Address - Fax:612-775-8005
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28116207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1679548879Medicaid
MN1679548879Medicaid
E22928Medicare UPIN