Healthcare Provider Details

I. General information

NPI: 1710249743
Provider Name (Legal Business Name): BRANDON BERT CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 E POLSTON AVE
POST FALLS ID
83854-6245
US

IV. Provider business mailing address

1651 E POLSTON AVE
POST FALLS ID
83854-6245
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-4208
  • Fax: 208-457-4197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number1081402
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: