Provider Demographics
NPI:1841270824
Name:CARLSON, INGRID (MD)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
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 1:395 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-5231
Mailing Address - Country:US
Mailing Address - Phone:904-466-2841
Mailing Address - Fax:
Practice Address - Street 1:395 3RD ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-5231
Practice Address - Country:US
Practice Address - Phone:904-466-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016275207V00000X
KY47025207V00000X
GA62087207VG0400X
MO2019016072207VG0400X
FLME112115207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME014001OtherMEDICARE TYPE UNSPECIFIED
MEH93848Medicare UPIN
MEH93848Medicare UPIN
MEME0140Medicare ID - Type Unspecified