Provider Demographics
NPI:1558518290
Name:CAROLLO, JOHN ANDREW JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:CAROLLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 MONTGOMERY DR APT 36
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5597
Mailing Address - Country:US
Mailing Address - Phone:707-579-6896
Mailing Address - Fax:
Practice Address - Street 1:5555 MONTGOMERY DR APT 36
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5597
Practice Address - Country:US
Practice Address - Phone:707-579-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE18635207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine