Provider Demographics
NPI:1114100989
Name:JOHN T. CARROLL, DPM PC
Entity Type:Organization
Organization Name:JOHN T. CARROLL, DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-510-0502
Mailing Address - Street 1:455 BOSTON POST RD, UNIT #8
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1554
Mailing Address - Country:US
Mailing Address - Phone:860-510-0502
Mailing Address - Fax:860-510-0551
Practice Address - Street 1:455 BOSTON POST RD, UNIT #8
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1554
Practice Address - Country:US
Practice Address - Phone:860-510-0502
Practice Address - Fax:860-510-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008063266OtherMEDICAID DME/MEDICAL SUPPLY DEALER
CT008059379Medicaid
CT008059379Medicaid
CTD100032362Medicare PIN