Provider Demographics
NPI:1083662324
Name:CARLSON, MISTY DAWN (DO)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DAWN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 TREELINE PARK
Mailing Address - Street 2:#1315
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1882
Mailing Address - Country:US
Mailing Address - Phone:210-364-0960
Mailing Address - Fax:
Practice Address - Street 1:BAMC 3851 ROGER BROOKE DR
Practice Address - Street 2:MCHE-QD (CRED)
Practice Address - City:FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-6200
Practice Address - Country:US
Practice Address - Phone:210-916-3027
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine