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1790775450

NPI Code Detail

MEDICARE: DEREK CARL CARLSON MD

MEDICARE: DEREK CARL 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	2084P0804X	Child & Adolescent Psychiatry Physician	4301106248	MI
2	2084P0804X	Child & Adolescent Psychiatry Physician	61608-20	WI

General Provider Information

NPI Number	:	1790775450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK CARL CARLSON MD

Provider Business Mailing Address
First Line	:	301 E SAINT JOSEPH ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-2241
Country	:	US
Telephone Number	:	920-433-3630
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 E SAINT JOSEPH ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-2241
Country	:	US
Telephone Number	:	920-433-3630
Fax Number	:

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

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	11/23/2020

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Directions to “ DEREK CARL CARLSON MD” Practice Location

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