Provider Demographics
NPI:1952332702
Name:CARLSON, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
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 1:2323 TWINBERRY AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1169
Mailing Address - Country:US
Mailing Address - Phone:503-371-7641
Mailing Address - Fax:
Practice Address - Street 1:121 SE VIEWMONT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1968
Practice Address - Country:US
Practice Address - Phone:541-766-3546
Practice Address - Fax:541-766-6143
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287244Medicaid