Provider Demographics
NPI:1932142858
Name:CARLSON, ROY DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:DOUGLAS
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:PO BOX 95000-5585
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-5585
Mailing Address - Country:US
Mailing Address - Phone:856-667-1575
Mailing Address - Fax:856-946-1747
Practice Address - Street 1:204 ARK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3100
Practice Address - Country:US
Practice Address - Phone:856-602-4000
Practice Address - Fax:856-946-1747
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA46109207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0371408Medicaid
NJ0371408Medicaid