Provider Demographics
NPI:1760414833
Name:CARLSON, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:635 N WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1317
Mailing Address - Country:US
Mailing Address - Phone:804-798-9208
Mailing Address - Fax:804-798-8108
Practice Address - Street 1:635 N WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1317
Practice Address - Country:US
Practice Address - Phone:804-798-9208
Practice Address - Fax:804-798-8108
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005821274Medicaid
VA223935OtherANTHEM BCBS OF VA
VA2263771OtherCIGNA
VA84862OtherSENTARA
VA267461OtherMAMSI
VA5080654OtherAETNA HMO
VA110170591OtherRAILROAD MEDICARE
VA5080654OtherAETNA LIFE
VA84862OtherSOUTHERN HEALTH SERVICES
VAC05704OtherGROUP PTAN
VA84862OtherSOUTHERN HEALTH SERVICES