Provider Demographics
NPI:1700058310
Name:CARLSON, JOHN CLIFFORD (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLIFFORD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 TULANE AVE # SL-37
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-5456
Mailing Address - Fax:504-988-1771
Practice Address - Street 1:1430 TULANE AVE # SL-37
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2632
Practice Address - Country:US
Practice Address - Phone:504-988-5456
Practice Address - Fax:504-988-1771
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200766208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01870255Medicaid
LA1069612Medicaid
LA4P159Medicare PIN
MS01870255Medicaid