Provider Demographics
NPI:1700961406
Name:CARLSON, DAVID WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 BROADWAY BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3400
Mailing Address - Country:US
Mailing Address - Phone:972-240-1789
Mailing Address - Fax:972-240-5525
Practice Address - Street 1:4402 BROADWAY BLVD STE 1
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-3400
Practice Address - Country:US
Practice Address - Phone:972-240-1789
Practice Address - Fax:972-240-5525
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B20YMedicare ID - Type Unspecified
TXC14201Medicare UPIN