Healthcare Provider Details

I. General information

NPI: 1023271137
Provider Name (Legal Business Name): RUSSELL MARTIN CARLSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6152
US

IV. Provider business mailing address

520 VALLEY VIEW DR
MOLINE IL
61265-6152
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax: 309-762-3690
Mailing address:
  • Phone: 309-762-3621
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135000650
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: