Provider Demographics
NPI:1265968424
Name:CARLSON, ALEC JAMES (IDC)
Entity type:Individual
Prefix:MR
First Name:ALEC
Middle Name:JAMES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS TYPHOON PC 5
Mailing Address - Street 2:UNIT 100286 BOX 1
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 HORNET AVE STE 101
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-3530
Practice Address - Country:US
Practice Address - Phone:619-537-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACARLAJ138NJ1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman