Individual
DR. MARK EDWIN CARLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1848 DAIMLER RD, ROCKFORD, IL 61112-1019
(815) 398-9100
(815) 986-6770
Mailing address
1848 DAIMLER RD, ROCKFORD, IL 61112-1019
(815) 398-9100
(815) 986-6770
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
036-073115
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36073065
—
IL
01
—
K52428
MEDICARE PTAN
IL
Enumeration date
04/25/2006
Last updated
09/07/2010
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