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General NPI Number Information
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NPI Number | 1518412238
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Entity Type | Organization
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Legal Business Name | CARLSON MEDICAL, PLLC
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Dates
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Enumeration Date | 08/23/2016
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Last Update Date | 08/23/2016
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Provider Practice Location Address
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Address Line | 486 TOWN PLAZA AVE SUITE 440
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5141
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Country | US
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Telephone | 904-395-3577
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Fax | 904-834-7821
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Provider Business Mailing Address
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Address Line | 486 TOWN PLAZA AVE SUITE 440
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5141
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Country | US
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Telephone | 904-395-3577
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Fax | 904-834-7821
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. INGRID A CARLSON
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Credential | MD
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Telephone | 904-395-3577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | ME112115
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License Number State | FL
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