Healthcare Provider Details

I. General information

NPI: 1508075540
Provider Name (Legal Business Name): CARL J CARLSON MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 MOWRY AVE SUITE #100
FREMONT CA
94538-1737
US

IV. Provider business mailing address

1895 MOWRY AVE SUITE #100
FREMONT CA
94538-1737
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

VIII. Authorized Official

Name: CATHERINE CARLSON
Title or Position: OFFICE MANAGER
Credential: R.N.
Phone: 510-792-2012