1174560270 NPI number — RICHARD CARLSON MD,PHD

Table of content: RICHARD CARLSON MD,PHD (NPI 1174560270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174560270 NPI number — RICHARD CARLSON MD,PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
RICHARD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD,PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174560270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3255 E ELWOOD ST
Provider Second Line Business Mailing Address:
#110
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85034-7256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-470-5043
Provider Business Mailing Address Fax Number:
602-470-5064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 E ROOSEVELT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-4948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-344-1015
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X , with the licence number:  23785 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)