Provider Demographics
NPI:1053534172
Name:CARLSON, RYAN M (DO)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 BLAZER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3566
Mailing Address - Country:US
Mailing Address - Phone:614-761-1151
Mailing Address - Fax:614-761-4893
Practice Address - Street 1:1933 OHIO DRIVE
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4835
Practice Address - Country:US
Practice Address - Phone:614-277-9530
Practice Address - Fax:614-277-2227
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016570207N00000X
OH34.009281207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2851301Medicaid
OH2851301Medicaid
HI4242251Medicare PIN