Healthcare Provider Details

I. General information

NPI: 1265799027
Provider Name (Legal Business Name): MATTHEW DAVID CARLSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N 45TH ST
SEATTLE WA
98103-6909
US

IV. Provider business mailing address

2501 N 45TH ST
SEATTLE WA
98103-6909
US

V. Phone/Fax

Practice location:
  • Phone: 206-526-5222
  • Fax:
Mailing address:
  • Phone: 206-526-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOD60373317
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60373317
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: