Provider Demographics
NPI:1043378912
Name:CARLSON, GREGG W (MD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:W
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2857
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:310 S PENN ST
Practice Address - Street 2:STE 204
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4553
Practice Address - Country:US
Practice Address - Phone:605-225-1636
Practice Address - Fax:605-229-2434
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD1897207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15824OtherND MEDICAID
SDS103765Medicare PIN