Provider Demographics
NPI:1912989864
Name:CARLSON, GARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2805 5TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6003
Practice Address - Country:US
Practice Address - Phone:605-719-5700
Practice Address - Fax:605-719-5701
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2013-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SD2158207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDD25207Medicare UPIN
SDS101733Medicare PIN