Healthcare Provider Details

I. General information

NPI: 1164425575
Provider Name (Legal Business Name): JOHN CAUDELL CARSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W WASHINGTON AVE
RICHLAND MO
65556-7101
US

IV. Provider business mailing address

304 W WASHINGTON AVE
RICHLAND MO
65556-7101
US

V. Phone/Fax

Practice location:
  • Phone: 877-406-2662
  • Fax: 573-723-1474
Mailing address:
  • Phone: 877-406-2662
  • Fax: 573-814-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024028733
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.000127
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: