Provider Demographics
NPI:1598751448
Name:CARROLL, CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
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 1:108 W KIOWA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:KS
Mailing Address - Zip Code:66536-1858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 W BERTRAND AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:KS
Practice Address - Zip Code:66536-1617
Practice Address - Country:US
Practice Address - Phone:785-321-9000
Practice Address - Fax:785-588-4348
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100118430DMedicaid
KS110428006OtherMEDICARE B
KS110428006OtherMEDICARE B
KS105169Medicare ID - Type Unspecified