Healthcare Provider Details

I. General information

NPI: 1093911885
Provider Name (Legal Business Name): DEREK MIKEL CARLSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number03325
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number252015-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number252015-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number03325
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: