Provider Demographics
NPI:1386617223
Name:CARLSON, SIMON PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:PAUL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PARK BEND DR BLDG 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5387
Mailing Address - Country:US
Mailing Address - Phone:512-351-8386
Mailing Address - Fax:
Practice Address - Street 1:2200 PARK BEND DR BLDG 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5387
Practice Address - Country:US
Practice Address - Phone:512-351-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00630792085R0202X
TXM91962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKA80OtherB/C B/S
TX197038606Medicaid
TX197038604Medicaid
DC2849OtherB/C B/S
MD409116700Medicaid
MDJ062OtherB/C B/S
MD434LM657Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 01
MD435LM656Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 02
TX197038606Medicaid
TXTXB105167Medicare PIN
MDKA80OtherB/C B/S
MD018191A00Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 99
DEDD4343Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD409116700Medicaid
TX197038604Medicaid