Healthcare Provider Details

I. General information

NPI: 1003874660
Provider Name (Legal Business Name): JOHN V CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E MONROE ST
MEXICO MO
65265-2919
US

IV. Provider business mailing address

200 PORTLAND ST
COLUMBIA MO
65201-6525
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-8292
  • Fax: 573-582-3292
Mailing address:
  • Phone: 573-886-4600
  • Fax: 573-886-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberR6C28
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: