Provider Demographics
NPI:1770545709
Name:CARLSON, GARY R (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3433 BROADWAY ST NE
Mailing Address - Street 2:STE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1761
Mailing Address - Country:US
Mailing Address - Phone:763-587-7737
Mailing Address - Fax:763-587-7069
Practice Address - Street 1:2833 CHICAGO AVE. SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3799
Practice Address - Country:US
Practice Address - Phone:612-863-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN30898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN416385100Medicaid
MN080015315Medicare PIN
MN416385100Medicaid