Provider Demographics
NPI:1487698395
Name:CARLETON, LINN HAZE (DO)
Entity type:Individual
Prefix:
First Name:LINN
Middle Name:HAZE
Last Name:CARLETON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 E ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-5338
Mailing Address - Country:US
Mailing Address - Phone:267-254-8553
Mailing Address - Fax:
Practice Address - Street 1:2642 E ONTARIO ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-5338
Practice Address - Country:US
Practice Address - Phone:215-425-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-003570-L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0058090000OtherBLUE SHIELD
PA442012340OtherUNITED HEALTHCARE
PA0124383600Medicaid
PA138368Medicare ID - Type Unspecified
PA0058090000OtherBLUE SHIELD