Provider Demographics
NPI:1851300545
Name:CARLSON, JUDITH A (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-780-4260
Mailing Address - Fax:262-780-4261
Practice Address - Street 1:19475 W NORTH AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4199
Practice Address - Country:US
Practice Address - Phone:262-780-4260
Practice Address - Fax:262-780-4261
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI252162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30709800Medicaid
WI30709800Medicaid
WI68480Medicare ID - Type Unspecified