Provider Demographics
NPI:1609834076
Name:CARLSEN, JEFFREY O (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:O
Last Name:CARLSEN
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 1:110 MED TECH PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4004
Mailing Address - Country:US
Mailing Address - Phone:423-929-2111
Mailing Address - Fax:423-929-0497
Practice Address - Street 1:110 MED TECH PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4004
Practice Address - Country:US
Practice Address - Phone:423-929-2111
Practice Address - Fax:423-929-0497
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38624207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00163835OtherPALMETTO RAILROAD MEDICAR
TN3898262Medicaid
TN3898262Medicare PIN
TNH88442Medicare UPIN
TN3898262Medicaid
TN0284010002Medicare NSC