Provider Demographics
NPI:1760757066
Name:DOUGLAS CARLSON DO, PA
Entity Type:Organization
Organization Name:DOUGLAS CARLSON DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-430-0626
Mailing Address - Street 1:4504 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-7488
Mailing Address - Country:US
Mailing Address - Phone:479-430-0626
Mailing Address - Fax:
Practice Address - Street 1:4504 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-7488
Practice Address - Country:US
Practice Address - Phone:479-430-0626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
ARE4230208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty