Provider Demographics
NPI:1982651287
Name:CARLSON, JERRY DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DALE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1150
Mailing Address - Country:US
Mailing Address - Phone:801-798-3557
Mailing Address - Fax:
Practice Address - Street 1:955 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1150
Practice Address - Country:US
Practice Address - Phone:801-798-3557
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5154950-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU99383Medicare UPIN