Provider Demographics
NPI:1619358900
Name:CARROLL, GRETTA (MD)
Entity Type:Individual
Prefix:
First Name:GRETTA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-8273
Mailing Address - Country:US
Mailing Address - Phone:575-572-7091
Mailing Address - Fax:
Practice Address - Street 1:280 1ST ST
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-7091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine