Provider Demographics
NPI:1649200262
Name:CARLSON, TERESA L (OD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19960 LIONESS WAY
Mailing Address - Street 2:190
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134
Mailing Address - Country:US
Mailing Address - Phone:303-794-1111
Mailing Address - Fax:303-347-1341
Practice Address - Street 1:11960 LIONESS WAY
Practice Address - Street 2:190
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5640
Practice Address - Country:US
Practice Address - Phone:303-794-1111
Practice Address - Fax:303-347-1341
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC809935Medicare PIN