Provider Demographics
NPI:1932131596
Name:CARLSON, JOHN DALE (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DALE
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 1:205 W PINE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3423
Mailing Address - Country:US
Mailing Address - Phone:850-682-5332
Mailing Address - Fax:850-682-8486
Practice Address - Street 1:492 N WILSON ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3442
Practice Address - Country:US
Practice Address - Phone:850-682-5332
Practice Address - Fax:850-682-8486
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051484174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04566Medicare ID - Type UnspecifiedMEDICARE
FLD43070Medicare UPIN