Provider Demographics
NPI:1710970595
Name:CARROLL, KATHLEEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
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 1:336 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8155
Mailing Address - Country:US
Mailing Address - Phone:813-689-2466
Mailing Address - Fax:813-689-0435
Practice Address - Street 1:336 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8155
Practice Address - Country:US
Practice Address - Phone:813-689-2466
Practice Address - Fax:813-689-0435
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
FLME00769472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79367OtherBCBS ID
FLH86510Medicare UPIN
FL79367AMedicare ID - Type UnspecifiedMEDICARE ID