Provider Demographics
NPI:1942556873
Name:CARLSON, MICHAEL JOHN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300A N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:PA
Mailing Address - Zip Code:16232-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:82 TOWN RUN RD
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT CITY
Practice Address - State:PA
Practice Address - Zip Code:16224-1502
Practice Address - Country:US
Practice Address - Phone:814-275-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine