Provider Demographics
NPI:1417151440
Name:CARROLL, JOHN RAYMOND (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAYMOND
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ARDMORE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1325
Mailing Address - Country:US
Mailing Address - Phone:773-732-5288
Mailing Address - Fax:
Practice Address - Street 1:42 E. LAUREL RD, UDP AT UMDNJ-SOM
Practice Address - Street 2:DEPT. OF FAMILY MEDICINE, RM 2100
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084
Practice Address - Country:US
Practice Address - Phone:856-566-6330
Practice Address - Fax:856-566-6360
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program