Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | S00151 | IA |
NPI | 1013163971 |
---|---|
Provider Name | Dr. Carl William Carlson |
First Address | Bussey, IA 50044-8135 |
Second Address | Bussey, IA 50044-8135 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2008 |
Last Update Date | 12/08/2008 |