Healthcare Provider Details

I. General information

NPI: 1790723948
Provider Name (Legal Business Name): KENNETH P. CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MATLOCK RD SUITE 108
ARLINGTON TX
76015-2920
US

IV. Provider business mailing address

3125 MATLOCK RD SUITE 108
ARLINGTON TX
76015-2920
US

V. Phone/Fax

Practice location:
  • Phone: 817-468-3911
  • Fax: 817-468-0374
Mailing address:
  • Phone: 817-468-3911
  • Fax: 817-468-0374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE9141
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: