Provider Demographics
NPI:1790741049
Name:CARLSON, MARK EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
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 1:1848 DAIMLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1019
Mailing Address - Country:US
Mailing Address - Phone:815-398-9100
Mailing Address - Fax:815-986-6770
Practice Address - Street 1:1848 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1019
Practice Address - Country:US
Practice Address - Phone:815-398-9100
Practice Address - Fax:815-986-6770
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073115174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK52428OtherMEDICARE PTAN
IL36073065Medicaid
IL36073065Medicaid
IL6246430001Medicare NSC