MEDICARE: VERA B CARLSON MD, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5916429-8905	UT

General Provider Information

NPI Number	:	1023095585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERA B CARLSON MD, PHD

Provider Business Mailing Address
First Line	:	169 N GATEWAY DR STE 170
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-9855
Country	:	US
Telephone Number	:	435-752-5553
Fax Number	:	435-755-5043

Provider Business Practice Location Address
First Line	:	565 W 465 N STE 130
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-4802
Country	:	US
Telephone Number	:	435-752-5553
Fax Number	:	435-755-5043

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	01/31/2024

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Directions to “ VERA B CARLSON MD, PHD” Practice Location

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