Provider Demographics
NPI:1891723268
Name:CARLSON, CARRIE JANE (DO)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JANE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5117 S CROSSING PL STE 3
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5270
Mailing Address - Country:US
Mailing Address - Phone:605-351-1549
Mailing Address - Fax:605-271-3376
Practice Address - Street 1:5117 S CROSSING PL STE 3
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5270
Practice Address - Country:US
Practice Address - Phone:605-351-1549
Practice Address - Fax:605-271-3376
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5610953Medicaid
SD5610953Medicaid
SDS100752Medicare PIN