Healthcare Provider Details

I. General information

NPI: 1508178799
Provider Name (Legal Business Name): JON BRANDON CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2010
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 3005B
SAINT LOUIS MO
63141-8266
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 3005B
SAINT LOUIS MO
63141-8266
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7070
  • Fax:
Mailing address:
  • Phone: 314-251-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number48167
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2024037003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: