Healthcare Provider Details

I. General information

NPI: 1649257825
Provider Name (Legal Business Name): KEVIN L CARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3886 PRINCETON LAKES WAY SW STE 100
ATLANTA GA
30331-5511
US

IV. Provider business mailing address

3886 PRINCETON LAKES WAY SW STE 100
ATLANTA GA
30331-5511
US

V. Phone/Fax

Practice location:
  • Phone: 770-506-4007
  • Fax: 678-246-5191
Mailing address:
  • Phone: 770-506-4007
  • Fax: 678-246-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number043894
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: