Provider Demographics
NPI:1437142858
Name:O CARROLL, DANIEL THOMAS (DPM, DABPS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:O CARROLL
Suffix:
Gender:M
Credentials:DPM, DABPS
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 4497
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-4497
Mailing Address - Country:US
Mailing Address - Phone:630-790-4442
Mailing Address - Fax:630-790-9472
Practice Address - Street 1:22W654 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6957
Practice Address - Country:US
Practice Address - Phone:630-790-4442
Practice Address - Fax:630-790-9472
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003265213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL626570OtherMEDICARE PTAN
IL016003265Medicaid
IL1145580001Medicare NSC
IL626570OtherMEDICARE PTAN