Healthcare Provider Details

I. General information

NPI: 1215924329
Provider Name (Legal Business Name): GREGORY D. CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W. LA VETA AVENUE SUITE 300
ORANGE CA
92868-4246
US

IV. Provider business mailing address

1120 W LA VETA AVE STE 300
ORANGE CA
92868-4246
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-1745
  • Fax: 714-941-9539
Mailing address:
  • Phone: 714-598-1745
  • Fax: 714-941-9539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG65319
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG65319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: