Provider Demographics
NPI:1003846353
Name:CARROLL, CHARLES SHANNON (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SHANNON
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 E LAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9527
Mailing Address - Country:US
Mailing Address - Phone:601-936-9190
Mailing Address - Fax:601-932-6714
Practice Address - Street 1:291 E LAYFAIR DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9527
Practice Address - Country:US
Practice Address - Phone:601-936-9190
Practice Address - Fax:601-932-6714
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15901207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120136Medicaid
MS160000517Medicare ID - Type UnspecifiedMCRE INDIVIDUAL NUMBER
MS00120136Medicaid