Healthcare Provider Details

I. General information

NPI: 1508921016
Provider Name (Legal Business Name): BRUCE D. CARLSON M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
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 Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMI J FOSTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-567-1137