Provider Demographics
NPI:1750359832
Name:CARLSON, PHILIP R (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
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 1:6696 WOLF HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:WI
Mailing Address - Zip Code:53598-9813
Mailing Address - Country:US
Mailing Address - Phone:608-842-0734
Mailing Address - Fax:
Practice Address - Street 1:6696 WOLF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:WI
Practice Address - Zip Code:53598
Practice Address - Country:US
Practice Address - Phone:608-842-0734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI262652085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology