Healthcare Provider Details

I. General information

NPI: 1174865588
Provider Name (Legal Business Name): GEOFFREY S CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2013
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5107
  • Fax:
Mailing address:
  • Phone: 707-423-5107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number0101257370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: