MEDICARE: DR. DIANE L CARLSON MD

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	207336	NY
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	ME100065	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME100065	OTHER	FL	FLORIDA DEPT OF HEALTH

General Provider Information

NPI Number	:	1164402152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE L CARLSON MD

Provider Business Mailing Address
First Line	:	15710 LINDBERGH LN
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-8312
Country	:	US
Telephone Number	:	631-871-4027
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 WESTON RD
Second Line	:	DEPT OF PATHOLOGY
City	:	WESTON
State	:	FL
Zip	:	33331-3602
Country	:	US
Telephone Number	:	954-689-5173
Fax Number	:

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	11/15/2021

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