Provider Demographics
NPI:1215924329
Name:CARLSON, GREGORY D (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1120 W LA VETA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4246
Mailing Address - Country:US
Mailing Address - Phone:714-598-1745
Mailing Address - Fax:714-941-9539
Practice Address - Street 1:1120 W. LA VETA AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4246
Practice Address - Country:US
Practice Address - Phone:714-598-1745
Practice Address - Fax:714-941-9539
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65319207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB234935OtherINDIVIDUAL PTAN
CACB234935OtherINDIVIDUAL PTAN