Provider Demographics
NPI:1184736498
Name:CARLSON, MARK D (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2401 S TUCKER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6619
Mailing Address - Country:US
Mailing Address - Phone:620-231-1650
Mailing Address - Fax:620-231-1685
Practice Address - Street 1:2401 S TUCKER AVE STE 1
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6619
Practice Address - Country:US
Practice Address - Phone:620-231-1650
Practice Address - Fax:620-231-1685
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-22890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E60644Medicare UPIN
020172Medicare PIN