Provider Demographics
NPI:1184735854
Name:CARLSON, JOHN ELLERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLERT
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 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5700
Mailing Address - Fax:216-255-5701
Practice Address - Street 1:9764 COUNTRY CREEK WAY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-9242
Practice Address - Country:US
Practice Address - Phone:937-885-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350683592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0460497Medicaid
OHCA4169141Medicare PIN
OH0460497Medicaid
OHCA4169143Medicare PIN
OHCA4169142Medicare PIN