Provider Demographics
NPI:1023095585
Name:CARLSON, VERA B (MD, PHD)
Entity type:Individual
Prefix:
First Name:VERA
Middle Name:B
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 170
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9855
Mailing Address - Country:US
Mailing Address - Phone:435-752-5553
Mailing Address - Fax:435-755-5043
Practice Address - Street 1:565 W 465 N STE 130
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-4802
Practice Address - Country:US
Practice Address - Phone:435-752-5553
Practice Address - Fax:435-755-5043
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5916429-8905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI23766Medicare UPIN
UT005810901Medicare PIN