Provider Demographics
NPI:1871507228
Name:CARSON, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:CARSON
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 1:92 CAMPUS DR STE D
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7229
Mailing Address - Country:US
Mailing Address - Phone:207-662-8900
Mailing Address - Fax:
Practice Address - Street 1:92 CAMPUS DR STE D
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7229
Practice Address - Country:US
Practice Address - Phone:207-662-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36117446208600000X, 2086S0129X
CAA85584208600000X, 2086S0129X
MEMD216252086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1871507228Medicaid