MEDICARE: KENNETH P. CARLSON, M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	E9141	DC

General Provider Information

NPI Number	:	1336303452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH P. CARLSON, M.D.

Provider Business Mailing Address
First Line	:	3125 MATLOCK RD
Second Line	:	SUITE 108
City	:	ARLINGTON
State	:	TX
Zip	:	76015-2920
Country	:	US
Telephone Number	:	817-468-3911
Fax Number	:	817-468-0374

Provider Business Practice Location Address
First Line	:	3125 MATLOCK RD
Second Line	:	SUITE 108
City	:	ARLINGTON
State	:	TX
Zip	:	76015-2920
Country	:	US
Telephone Number	:	817-468-3911
Fax Number	:	817-468-0374

Authorized Official
Title or Position	:	DOCTOR
Name	:	KENNETH PHILLIP CARLSON
Credential	:	M.D.
Telephone Number	:	817-468-3911

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	07/17/2008

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