Healthcare Provider Details

I. General information

NPI: 1790775450
Provider Name (Legal Business Name): DEREK CARL CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E SAINT JOSEPH ST
GREEN BAY WI
54301-2241
US

IV. Provider business mailing address

301 E SAINT JOSEPH ST
GREEN BAY WI
54301-2241
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3630
  • Fax:
Mailing address:
  • Phone: 920-433-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301106248
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number61608-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: