Basic Information
| Provider Information | |||||||||
| NPI: | 1417926015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1458 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672011458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162624467 | ||||||||
| FaxNumber: | 3162620706 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLLEGE AVE | ||||||||
| Address2: | SUITE E-110 | ||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855372651 | ||||||||
| FaxNumber: | 7855372975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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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 | 207RX0202X | 0424120 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 100143440B | 05 | KS | MEDICAID |