Provider Demographics
NPI:1073577938
Name:CARLSON, JOANNE L (MD)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:CARLSON
Other - Last Name:KURTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP PEDIATRIC DEPT.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224192208000000X
FLME97112208M00000X, 208000000X
FLME98112208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2778378-00Medicaid
FL277837800Medicaid
FL679675487BMedicaid
GA679675487CMedicaid
FL93557OtherBCBS
I19695Medicare UPIN
FL2778378-00Medicaid