Provider Demographics
NPI:1750386199
Name:CARLSON, SCOTT ALLAN (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLAN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-8632
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:231-882-9616
Practice Address - Street 1:2198 US 31 S
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-723-3567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC008093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3015713Medicaid
MIOM71710Medicare ID - Type Unspecified
MI3015713Medicaid