Provider Demographics
NPI:1508946054
Name:CARROLL, JOHN T (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 PARKWAY S 302
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-447-1488
Mailing Address - Fax:860-447-1489
Practice Address - Street 1:455 BOSTON POST RD STE 8
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1554
Practice Address - Country:US
Practice Address - Phone:860-510-0502
Practice Address - Fax:860-510-0551
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000027213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004006276Medicaid
CTD400032363Medicare PIN
CT4895660001Medicare NSC
CT004006276Medicaid