Provider Demographics
NPI:1639306566
Name:CARROLL, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1108
Mailing Address - Country:US
Mailing Address - Phone:208-381-2094
Mailing Address - Fax:208-381-1791
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2094
Practice Address - Fax:208-381-1791
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0565202085R0202X
IDM-128232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology