Provider Demographics
NPI:1952332702
Name:CARLSON, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
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 1:1475 MOUNT HOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9099
Mailing Address - Country:US
Mailing Address - Phone:503-982-0626
Mailing Address - Fax:
Practice Address - Street 1:1475 MOUNT HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9099
Practice Address - Country:US
Practice Address - Phone:503-981-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287244Medicaid