Basic Information
| Provider Information | |||||||||
| NPI: | 1346271939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102025709 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 S WALKER ST | ||||||||
| Address2: | |||||||||
| City: | BURGAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102594526 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD-056448-L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2010-01823 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5915983 | 05 | NC | MEDICAID | 161CU | 01 | NC | BCBSNC | OTHER |