Provider Demographics
NPI:1104800994
Name:CARLSON, JAMES MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2400 NE NEFF RD
Mailing Address - Street 2:STE A
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6752
Mailing Address - Country:US
Mailing Address - Phone:541-389-3300
Mailing Address - Fax:541-389-8115
Practice Address - Street 1:2400 NE NEFF RD
Practice Address - Street 2:STE A
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6752
Practice Address - Country:US
Practice Address - Phone:541-389-3300
Practice Address - Fax:541-389-8115
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23967207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286583Medicaid
ORR112948Medicare PIN
OR286583Medicaid
ORDO23967OtherMEDICAL LICENSE OREGON
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR0577260001OtherDMERC NUMBER
ORR0000WFBTVOtherGROUP PIN NUMBER
ORH67067Medicare UPIN