MEDICARE: MARK O. CARLSON M.D.

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	207R00000X	Internal Medicine Physician	27247	IA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	IB1201001	OTHER	IA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609837368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK O. CARLSON M.D.

Provider Business Mailing Address
First Line	:	1605 DOUGLAS ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51105-1109
Country	:	US
Telephone Number	:	712-234-1005
Fax Number	:	712-234-0015

Provider Business Practice Location Address
First Line	:	1605 DOUGLAS ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51105-1109
Country	:	US
Telephone Number	:	712-234-1005
Fax Number	:	712-234-0015

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

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	11/22/2012

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Directions to “ MARK O. CARLSON M.D.” Practice Location

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