Provider Demographics
NPI:1528181245
Name:CARLSON, STEPHEN JOHN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
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:N2296 LITTLE LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-8826
Mailing Address - Country:US
Mailing Address - Phone:715-468-2205
Mailing Address - Fax:
Practice Address - Street 1:819 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1201
Practice Address - Country:US
Practice Address - Phone:715-635-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB51959Medicare UPIN