1255718367 NPI number — DR. KYLE RICHARD CARLSON D.O.

Table of content: DR. KYLE RICHARD CARLSON D.O. (NPI 1255718367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255718367 NPI number — DR. KYLE RICHARD CARLSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
KYLE
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1255718367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5052 N CLINTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-408-2203
Provider Business Mailing Address Fax Number:
260-408-8014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 PROVIDENT DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46580-3297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-8551
Provider Business Practice Location Address Fax Number:
260-482-5060
Provider Enumeration Date:
04/28/2015

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: 207X00000X , with the licence number:  02006490A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300052895 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com