Provider Demographics
NPI:1386694438
Name:CARLSON, GREGORY B (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:B
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-416-6025
Mailing Address - Fax:
Practice Address - Street 1:5012 S US HIGHWAY 75
Practice Address - Street 2:SUITE 300
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4587
Practice Address - Country:US
Practice Address - Phone:903-416-6025
Practice Address - Fax:903-416-6138
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK0666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044508201Medicaid
TX85Y237Medicare PIN
TX044508201Medicaid