Provider Demographics
NPI:1164425575
Name:CARSON, JOHN CAUDELL (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CAUDELL
Last Name:CARSON
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 1:304 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-7101
Mailing Address - Country:US
Mailing Address - Phone:877-406-2662
Mailing Address - Fax:573-814-6177
Practice Address - Street 1:304 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MO
Practice Address - Zip Code:65556-7101
Practice Address - Country:US
Practice Address - Phone:877-406-2662
Practice Address - Fax:573-723-1474
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024028733207Q00000X
LADO.000127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G04728Medicare UPIN