Provider Demographics
NPI:1639131329
Name:CARROLL, MARC L (DO)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5345 HENDRON RD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-1055
Mailing Address - Country:US
Mailing Address - Phone:614-835-0070
Mailing Address - Fax:614-835-0301
Practice Address - Street 1:5345 HENDRON RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1055
Practice Address - Country:US
Practice Address - Phone:614-835-0070
Practice Address - Fax:614-835-0301
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0562243Medicaid
OHA15347Medicare UPIN
OHCA0528533Medicare ID - Type Unspecified