Provider Demographics
NPI:1710030002
Name:CARLSON, ROBERT LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:CARLSON
Suffix:JR
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 1:3970 BELLINGRATH MAIN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6020
Mailing Address - Country:US
Mailing Address - Phone:770-794-1157
Mailing Address - Fax:678-797-6278
Practice Address - Street 1:3900 LEGACY PARK BLVD NW
Practice Address - Street 2:SUITE C-100
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7412
Practice Address - Country:US
Practice Address - Phone:678-797-6277
Practice Address - Fax:678-797-6278
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043890207PE0004X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Not Answered207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00770459CMedicaid
GA93BDPGRMedicare ID - Type Unspecified
GA00770459CMedicaid