Basic Information
| Provider Information | |||||||||
| NPI: | 1770545709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2833 CHICAGO AVE. SOUTH | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128633333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30898 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 416385100 | 05 | MN | MEDICAID |