Provider Demographics
NPI:1134486582
Name:CARROLL, BRYAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 HARRIS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4260
Mailing Address - Country:US
Mailing Address - Phone:817-292-3376
Mailing Address - Fax:844-886-8347
Practice Address - Street 1:6900 HARRIS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4260
Practice Address - Country:US
Practice Address - Phone:817-292-3376
Practice Address - Fax:844-886-8347
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6500207NP0225X, 207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX505391YMJCMedicare PIN