1043210131 NPI number — DR. COLLEEN M CARLSON PHARMD., CDM

Table of content: DR. COLLEEN M CARLSON PHARMD., CDM (NPI 1043210131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043210131 NPI number — DR. COLLEEN M CARLSON PHARMD., CDM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
COLLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD., CDM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORD
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043210131
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:
6501 LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR HEIGHTS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50322-5923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 51ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50265-2831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-221-2751
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2005

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: 183500000X , with the licence number:  19650 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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