Healthcare Provider Details

I. General information

NPI: 1013900174
Provider Name (Legal Business Name): ROBERT D CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 E MAIN ST
STAFFORD SPRINGS CT
06076-1227
US

IV. Provider business mailing address

47 E MAIN ST
STAFFORD SPRINGS CT
06076-1227
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5848
  • Fax:
Mailing address:
  • Phone: 860-684-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number029923
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: