Healthcare Provider Details

I. General information

NPI: 1669537106
Provider Name (Legal Business Name): BRUCE D CARLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 E NEWPORT AVE
HERMISTON OR
97838-2449
US

IV. Provider business mailing address

236 E NEWPORT AVE
HERMISTON OR
97838-2449
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-1137
  • Fax: 541-567-2336
Mailing address:
  • Phone: 541-567-1137
  • Fax: 541-567-2336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD07786
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: