Healthcare Provider Details

I. General information

NPI: 1053534172
Provider Name (Legal Business Name): RYAN M. CARLSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 OHIO DRIVE
GROVE CITY OH
43123-4835
US

IV. Provider business mailing address

5720 BLAZER PARKWAY
DUBLIN OH
43017-3566
US

V. Phone/Fax

Practice location:
  • Phone: 614-277-9530
  • Fax: 614-277-2227
Mailing address:
  • Phone: 614-761-1151
  • Fax: 614-761-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5101016570
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number34.009281
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34.009281
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: