Healthcare Provider Details

I. General information

NPI: 1386669489
Provider Name (Legal Business Name): CARL JEFFREY CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MOWRY AVE SUITE 220
FREMONT CA
94538-1700
US

IV. Provider business mailing address

2333 MOWRY AVE SUITE 220
FREMONT CA
94538-1700
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-2012
  • Fax: 510-792-7986
Mailing address:
  • Phone: 510-792-2012
  • Fax: 510-792-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG29295
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG29295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: