Healthcare Provider Details

I. General information

NPI: 1467542241
Provider Name (Legal Business Name): JOHN D CARLSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 HIGHWAY 51 S STE 6
HERNANDO MS
38632-1108
US

IV. Provider business mailing address

2170 HIGHWAY 51 S STE 6
HERNANDO MS
38632-1108
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-1384
  • Fax: 662-449-1385
Mailing address:
  • Phone: 662-449-1384
  • Fax: 662-449-1385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number671
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: