Provider Demographics
NPI:1063423515
Name:CARLSON, JOEL M (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DEWEY STREET
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-0005
Mailing Address - Country:US
Mailing Address - Phone:715-421-1001
Mailing Address - Fax:
Practice Address - Street 1:420 DEWEY STREET
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-0005
Practice Address - Country:US
Practice Address - Phone:715-421-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33239207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31818600Medicaid
WI31818600Medicaid
WI31818600Medicaid