Provider Demographics
NPI:1487607164
Name:ODEGARD, CARSON EDWARD (DC)
Entity type:Individual
Prefix:MR
First Name:CARSON
Middle Name:EDWARD
Last Name:ODEGARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 STATE ST
Mailing Address - Street 2:STE. #3
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033
Mailing Address - Country:US
Mailing Address - Phone:425-827-4646
Mailing Address - Fax:425-827-1941
Practice Address - Street 1:816 6TH ST S
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6714
Practice Address - Country:US
Practice Address - Phone:425-827-4646
Practice Address - Fax:425-827-1941
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1558302R00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA010752001OtherGROUP HEALTH
WA95126OtherLABOR & INDUSTRIES
WAOD-0076OtherREGENCE
WA391945651OtherCIGNA
WA1487607164Medicare PIN
WAOD-0076OtherREGENCE