Provider Demographics
NPI:1104930601
Name:CARLSON, KURTIS M (OD)
Entity type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305
Mailing Address - Country:US
Mailing Address - Phone:217-222-2020
Mailing Address - Fax:217-223-9582
Practice Address - Street 1:4929 OAK STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-2839
Practice Address - Country:US
Practice Address - Phone:217-222-2020
Practice Address - Fax:217-223-9582
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL132031OtherBLUE CROSS BLUE SHIELD
IL258761OtherHEALTHLINK
IL132031OtherBLUE CROSS BLUE SHIELD
IL258761OtherHEALTHLINK
4378400001Medicare NSC
4378400001Medicare NSC