Provider Demographics
NPI:1396790895
Name:CARLSON, INGRID A (MD)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6989
Mailing Address - Street 2:MSC 18913
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-6989
Mailing Address - Country:US
Mailing Address - Phone:206-858-7000
Mailing Address - Fax:206-858-7050
Practice Address - Street 1:10330 MERIDIAN AVE N
Practice Address - Street 2:SUITE 370
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9451
Practice Address - Country:US
Practice Address - Phone:206-528-6000
Practice Address - Fax:206-528-0014
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO38803207W00000X
WAMD60494692207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54902541Medicaid
CO54902541Medicaid
CO801752Medicare ID - Type Unspecified