Healthcare Provider Details

I. General information

NPI: 1962407585
Provider Name (Legal Business Name): THOMAS J CARLSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 200
BEND OR
97701-4281
US

IV. Provider business mailing address

2200 NE NEFF RD STE 200
BEND OR
97701-4281
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3344
  • Fax: 541-382-1681
Mailing address:
  • Phone: 541-382-3344
  • Fax: 541-382-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMD12666
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: