Provider Demographics
NPI:1184853749
Name:CARROLL, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 MITSCHER AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23551-2487
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1562 MITSCHER AVENUE
Practice Address - Street 2:SUITE 250
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23551-2487
Practice Address - Country:US
Practice Address - Phone:757-836-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD445329405300000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No208000000XAllopathic & Osteopathic PhysiciansPediatrics