Provider Demographics
NPI:1154484715
Name:CARROLL, TANNON DAJUAN (MD)
Entity Type:Individual
Prefix:
First Name:TANNON
Middle Name:DAJUAN
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 1:1400 N IH 35
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:512-324-8300
Mailing Address - Fax:512-324-8301
Practice Address - Street 1:301 SETON PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8002
Practice Address - Country:US
Practice Address - Phone:512-324-4812
Practice Address - Fax:512-324-4728
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7887207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328854003Medicaid
TX8DZ199OtherBCBS
TX328854004Medicaid
TX328854001Medicaid
TX8ET191OtherBCBS
TX322683YTMTMedicare PIN
TX8DZ199OtherBCBS
TX8ET191OtherBCBS
TX322683YMGJMedicare PIN