Provider Demographics
NPI:1538206644
Name:CARLSON, JONATHAN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1670 MAKALOA ST # 204-321
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3232
Mailing Address - Country:US
Mailing Address - Phone:808-452-1379
Mailing Address - Fax:808-201-4961
Practice Address - Street 1:40 AULIKE ST STE 411
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2757
Practice Address - Country:US
Practice Address - Phone:808-452-1379
Practice Address - Fax:808-201-4961
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95611207L00000X
AZ41788207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ41788OtherAZ LIC
AZ41788OtherAZ LIC