Provider Demographics
NPI:1376852301
Name:CARROLL, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:2727 W HEADING AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-4981
Mailing Address - Country:US
Mailing Address - Phone:309-648-1087
Mailing Address - Fax:
Practice Address - Street 1:2727 W HEADING AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-4981
Practice Address - Country:US
Practice Address - Phone:309-648-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.064215207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine