Provider Demographics
NPI:1144280181
Name:CARLSON, GARY ROY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ROY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 S WESTLAKE BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1929
Mailing Address - Country:US
Mailing Address - Phone:805-495-0551
Mailing Address - Fax:805-496-8079
Practice Address - Street 1:1240 S WESTLAKE BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-1929
Practice Address - Country:US
Practice Address - Phone:805-495-0551
Practice Address - Fax:805-496-8079
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47870Medicare UPIN
CAWG39594BMedicare ID - Type Unspecified