Provider Demographics
NPI:1134446875
Name:CARLSON, CHARLOTTE MARY (MD)
Entity type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:MARY
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2455 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7815
Mailing Address - Country:US
Mailing Address - Phone:707-308-2815
Mailing Address - Fax:707-573-5439
Practice Address - Street 1:2455 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7815
Practice Address - Country:US
Practice Address - Phone:707-308-2815
Practice Address - Fax:707-573-5439
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2020-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA1009320207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA119269OtherSTATE MEDICAL LICENSE