Provider Demographics
NPI:1407828007
Name:CARROLL, RICHARD PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PAUL
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 1:4887 E LAKE HARRIET BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5222
Mailing Address - Country:US
Mailing Address - Phone:612-325-0317
Mailing Address - Fax:
Practice Address - Street 1:4887 E LAKE HARRIET BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5222
Practice Address - Country:US
Practice Address - Phone:612-325-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21566174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN648872200Medicaid
MN6D561CAOtherBCBS PROVIDER NUMBER
WI31260500OtherWISCONSIN MA PROVIDER NO.
MN648872200Medicaid
MNCR4206Medicare PIN
WI31260500OtherWISCONSIN MA PROVIDER NO.
GA240001360Medicare PIN