Provider Demographics
NPI:1497931406
Name:CARROLL, JERRY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:SCOTT
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:734 N 3RD ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5285
Mailing Address - Country:US
Mailing Address - Phone:352-365-2583
Mailing Address - Fax:352-728-6749
Practice Address - Street 1:734 N 3RD ST
Practice Address - Street 2:SUITE 115
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5285
Practice Address - Country:US
Practice Address - Phone:352-365-2583
Practice Address - Fax:352-728-6749
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1096652085R0202X, 207RM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00986156OtherRR MEDICARE RACF
FLP00986170OtherRR MEDICARE LMIV
FL03876000Medicaid
FLP00986156OtherRR MEDICARE RACF
FL03876000Medicaid