Provider Demographics
NPI:1811981905
Name:CARLSON, KEVIN E (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 CHARTER DR
Mailing Address - Street 2:STE 200
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3629
Mailing Address - Country:US
Mailing Address - Phone:410-910-7444
Mailing Address - Fax:410-910-2310
Practice Address - Street 1:10700 CHARTER DR
Practice Address - Street 2:STE 200
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3629
Practice Address - Country:US
Practice Address - Phone:410-910-7444
Practice Address - Fax:410-910-2310
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD68747002OtherBC/BS OF MD
MD769200500Medicaid
DCB6100006OtherBC/BS OF DC
DCB6100006OtherBC/BS OF DC
242L340WMedicare ID - Type Unspecified