Healthcare Provider Details

I. General information

NPI: 1932365400
Provider Name (Legal Business Name): JOANN CARLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 FRENCH ST
NEW BRUNSWICK NJ
08901-1935
US

IV. Provider business mailing address

89 FRENCH ST
NEW BRUNSWICK NJ
08901-1935
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7880
  • Fax: 732-235-6620
Mailing address:
  • Phone: 732-235-7880
  • Fax: 732-235-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number25MA09496800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: