Provider Demographics
NPI:1265470421
Name:CARROLL, KEVIN W (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
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:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-332-5206
Practice Address - Street 1:3623 LATROBE DRIVE
Practice Address - Street 2:STE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-332-5206
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC350852085R0202X
FLME800382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7444122OtherAETNA PPO
SCQ35085Medicaid
FLME80038OtherFLORIDA LICENSE
2381250OtherAETNA HMO
NC35085OtherNC LICENSE
FL259310600Medicaid
35604OtherBCBS
FL259310600Medicaid
35604OtherBCBS
NC2275066AMedicare ID - Type UnspecifiedNC MEDICARE