Provider Demographics
NPI:1578507588
Name:CARROLL, JOHN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 MASON AVE
Mailing Address - Street 2:SUITE # 305
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5515
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:1673 MASON AVE
Practice Address - Street 2:SUITE # 305
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5515
Practice Address - Country:US
Practice Address - Phone:386-274-7118
Practice Address - Fax:386-274-6173
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00772952085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0203X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256064000Medicaid
FL46215OtherBLUE CROSS BLUE SHIELD
FLG19529Medicare UPIN
FL256064000Medicaid
FL46215OtherBLUE CROSS BLUE SHIELD
FL300098443Medicare PIN
FL46215YMedicare PIN