1114958055 NPI number — ALAN B CARLSON DPM

Table of content: ALAN B CARLSON DPM (NPI 1114958055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114958055 NPI number — ALAN B CARLSON DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
ALAN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1114958055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 E PUSCH VIEW LN
Provider Second Line Business Mailing Address:
SUTIE 130
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85737-9235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-877-3668
Provider Business Mailing Address Fax Number:
520-979-0125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 E PUSCH VIEW LN
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85737-9235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-877-3668
Provider Business Practice Location Address Fax Number:
520-797-0125
Provider Enumeration Date:
07/06/2006

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: 213E00000X , with the licence number:  449 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 694 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 103291 . This is a "UCARE - ROSEVILLE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 103295 . This is a "UCARE HIGHLAND" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 487052 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 504025600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64599CA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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