Provider Demographics
NPI:1689825564
Name:CARLSON, DIANA JOLYNN (DO)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:JOLYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 N POND DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3079
Mailing Address - Country:US
Mailing Address - Phone:248-624-2222
Mailing Address - Fax:248-926-9455
Practice Address - Street 1:100 N POND DR
Practice Address - Street 2:SUITE C
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3079
Practice Address - Country:US
Practice Address - Phone:248-624-2222
Practice Address - Fax:248-926-9455
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine