Provider Demographics
NPI:1285703959
Name:CARLSON, LARS JOHN (OD)
Entity type:Individual
Prefix:MR
First Name:LARS
Middle Name:JOHN
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 1:7314 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-4021
Mailing Address - Country:US
Mailing Address - Phone:602-373-8821
Mailing Address - Fax:
Practice Address - Street 1:5301 S SUPERSTITION MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85218-1919
Practice Address - Country:US
Practice Address - Phone:480-474-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0906570OtherBLUE CROSS BLUE SHIELD
AZAZ0906570OtherBLUE CROSS BLUE SHIELD
AZU92700Medicare UPIN