Provider Demographics
NPI:1609087121
Name:CARROLL, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
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 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-1000
Mailing Address - Fax:
Practice Address - Street 1:950 CLAGUE RD BLDG B
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1533
Practice Address - Country:US
Practice Address - Phone:216-844-8200
Practice Address - Fax:440-250-2022
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252291207N00000X
OH35.137019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10097097OtherOPTIMA HEALTH
VA1609087121OtherCOVENTRY HEALTH NETWORK
NC5921028Medicaid
VA1609087121OtherUNITED HEALTHCARE
VAPAROtherCIGNA
VAPAROtherMULTIPLAN
VA-005OtherTRICARE/CHAMPUS
VA473606OtherANTHEM BC/BS
VAPAROtherCORVEL
VAPAROtherAETNA
VA1609087121OtherVIRGINIA PREMIER HEALTH PLAN
VA1609087121Medicaid
VAPAROtherUSA MANAGED CARE
VAPAROtherVIRGINIA HEALTH NETWORK
VAPAROtherAETNA
NC5921028Medicaid