Provider Demographics
NPI:1396704680
Name:CARLON, DOUGLAS JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:CARLON
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 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-649-2007
Mailing Address - Fax:
Practice Address - Street 1:1895 N JASPER DR STE 1
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1632
Practice Address - Country:US
Practice Address - Phone:928-773-2332
Practice Address - Fax:623-524-8959
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ293142086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ694704Medicaid
AZ694704Medicaid
AZH61389Medicare UPIN
AZZ111889Medicare PIN