Provider Demographics
NPI:1740255462
Name:CARLSON, BRIAN J (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5440 W SAHARA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-0355
Mailing Address - Country:US
Mailing Address - Phone:702-633-0207
Mailing Address - Fax:209-532-1817
Practice Address - Street 1:2031 MCDANIEL ST
Practice Address - Street 2:SUITE 210
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6303
Practice Address - Country:US
Practice Address - Phone:702-633-0207
Practice Address - Fax:209-532-1817
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA00G732910207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100013695OtherRAILROAD MEDICARE
NV1740255462Medicaid
CA00G732910Medicaid
NVV50181Medicare PIN
CAF62393Medicare UPIN