Provider Demographics
NPI:1710976840
Name:CARROLL, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:1900 CROWN COLONY DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0931
Mailing Address - Country:US
Mailing Address - Phone:617-472-5242
Mailing Address - Fax:617-770-2975
Practice Address - Street 1:1900 CROWN COLONY DR
Practice Address - Street 2:SUITE 301
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0931
Practice Address - Country:US
Practice Address - Phone:617-472-5242
Practice Address - Fax:617-770-2975
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25738207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2000997Medicaid
MA2000997Medicaid
MAB51012Medicare ID - Type Unspecified