Healthcare Provider Details

I. General information

NPI: 1841270824
Provider Name (Legal Business Name): INGRID CARLSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 3RD ST
ATLANTIC BEACH FL
32233-5231
US

IV. Provider business mailing address

395 3RD ST
ATLANTIC BEACH FL
32233-5231
US

V. Phone/Fax

Practice location:
  • Phone: 904-466-2841
  • Fax:
Mailing address:
  • Phone: 904-466-2841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number016275
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number47025
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number62087
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2019016072
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME112115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: