Provider Demographics
NPI:1336133768
Name:O'CARROLL, BRIAN DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:O'CARROLL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 OAK PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3406
Mailing Address - Country:US
Mailing Address - Phone:805-481-9100
Mailing Address - Fax:805-481-9199
Practice Address - Street 1:911 OAK PARK BLVD
Practice Address - Street 2:STE 106
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3406
Practice Address - Country:US
Practice Address - Phone:805-481-9100
Practice Address - Fax:805-481-9199
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4758213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004922Medicaid
CAE4758OtherCA MED LICENSE
CA000E47580OtherBLUE SHIELD
ILU83422Medicare UPIN
CAET363ZMedicare PIN
CA000E47580OtherBLUE SHIELD
IL016004922Medicaid