Provider Demographics
NPI:1023140977
Name:CARLSTON, MICHAEL G (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:CARLSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:427 DOYLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4515
Mailing Address - Country:US
Mailing Address - Phone:707-545-1554
Mailing Address - Fax:707-545-1595
Practice Address - Street 1:2448 GUERNEVILLE RD
Practice Address - Street 2:SUITE 900
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7222
Practice Address - Country:US
Practice Address - Phone:707-545-1554
Practice Address - Fax:707-545-1595
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG54737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52786Medicare UPIN
CAG547370Medicare ID - Type Unspecified