Healthcare Provider Details

I. General information

NPI: 1366443392
Provider Name (Legal Business Name): BETH L CARLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 MATTHEWS MINT HILL RD
MATTHEWS NC
28105-3633
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-9920
  • Fax: 704-384-9925
Mailing address:
  • Phone: 704-384-9920
  • Fax: 704-384-9925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200500019
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME104131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: