Provider Demographics
NPI:1114927373
Name:CARROLL, CHARLES LOYD (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LOYD
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 1:4778 S SCATTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-2908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4778 S SCATTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-2908
Practice Address - Country:US
Practice Address - Phone:765-646-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001626A202C00000X, 207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000198187OtherBC/BS #
IN200031800Medicaid
IN080174096OtherRAILROAD
OH2000382Medicaid
IN000000198187OtherBC/BS #
IN080174096OtherRAILROAD
ING00528Medicare UPIN
IN168720EMedicare PIN