=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316039993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID ADELBERT CARLSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 BRADLEY ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-562-5579
-----------------------------------------------------
Fax | 203-458-7157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 BRADLEY ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-562-5579
-----------------------------------------------------
Fax | 203-458-7157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 010467
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------