Provider Demographics
NPI:1679548879
Name:CARLSON, KEITH HAROLD (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:HAROLD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14101 FAIRVIEW DR STE 350
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2506
Mailing Address - Country:US
Mailing Address - Phone:952-522-4900
Mailing Address - Fax:952-522-4901
Practice Address - Street 1:14101 FAIRVIEW DR STE 350
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2506
Practice Address - Country:US
Practice Address - Phone:952-522-4900
Practice Address - Fax:952-522-4901
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN28116207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1679548879Medicaid
MN1679548879Medicaid
E22928Medicare UPIN