Healthcare Provider Details

I. General information

NPI: 1538206644
Provider Name (Legal Business Name): JONATHAN DAVID CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 AULIKE ST STE 411
KAILUA HI
96734-2757
US

IV. Provider business mailing address

1670 MAKALOA ST # 204-321
HONOLULU HI
96814-3232
US

V. Phone/Fax

Practice location:
  • Phone: 808-452-1379
  • Fax: 808-201-4961
Mailing address:
  • Phone: 808-452-1379
  • Fax: 808-201-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA95611
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number41788
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number41788
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: