Healthcare Provider Details

I. General information

NPI: 1861718264
Provider Name (Legal Business Name): ROBERT D. CARLSON, M.D. , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
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

11 PHELPS WAY POB 399
WILLINGTON CT
06279
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5871
  • Fax: 860-684-0469
Mailing address:
  • Phone: 860-429-8439
  • Fax: 860-429-3145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT D CARLSON, M.D. , LLC
Title or Position: OWNER/MEMBER
Credential: M.D.
Phone: 860-429-8439