Basic Information
| Provider Information | |||||||||
| NPI: | 1356324214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | WALDO | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067797111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | 4301043955 | MI | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 2083P0500X | 4301043955 | MI | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine | 207R00000X | 4301043955 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30551400 | 05 | WI | MEDICAID | 3902200121 | 01 | MI | BCBS MI | OTHER | 110088084 | 01 | MI | RR MEDICARE | OTHER | 3228033 | 05 | MI | MEDICAID |