Healthcare Provider Details

I. General information

NPI: 1073590972
Provider Name (Legal Business Name): GREGORY CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BOULDER ST SUITE 600
COLORADO SPRINGS CO
80909-5533
US

IV. Provider business mailing address

1400 E BOULDER ST SUITE 600
COLORADO SPRINGS CO
80909-5533
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-6487
  • Fax: 719-364-6488
Mailing address:
  • Phone: 719-365-6487
  • Fax: 719-364-6488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0042262
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberDR.0042262
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: