Healthcare Provider Details

I. General information

NPI: 1497672786
Provider Name (Legal Business Name): COLTON CARLSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5020
US

IV. Provider business mailing address

14554 NE 50TH ST
CHOCTAW OK
73020-9522
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number50015
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number50015
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: