Provider Demographics
NPI:1194717413
Name:CARLSON, RAYMOND LIONEL (DO)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LIONEL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W WILLIAM AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-0026
Mailing Address - Country:US
Mailing Address - Phone:308-568-3730
Mailing Address - Fax:308-568-3738
Practice Address - Street 1:625 W WILLIAM AVE STE 210
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-0026
Practice Address - Country:US
Practice Address - Phone:308-568-3500
Practice Address - Fax:308-568-3738
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE224207R00000X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025770900Medicaid
NE47080978500Medicaid
NE098951Medicare PIN
NE10025770900Medicaid
NEG10542Medicare UPIN
NE47080978500Medicaid
NE283858Medicare Oscar/Certification
NEP00741716Medicare PIN