Provider Demographics
NPI:1578534277
Name:MCCARROLL, CONNIE JO (DO)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:MCCARROLL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 ALTAMONTE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-8048
Mailing Address - Country:US
Mailing Address - Phone:740-592-1230
Mailing Address - Fax:
Practice Address - Street 1:313 PARKS HALL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-2444
Practice Address - Fax:740-593-0905
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002567208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34002567OtherOHIO LICENSE
OH0535326Medicaid
OHAM8659180OtherDEA
OH0535326Medicaid