Provider Demographics
NPI:1750324620
Name:CARRACCIO, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:CARRACCIO
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:PO BOX 62063
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2063
Mailing Address - Country:US
Mailing Address - Phone:410-706-5181
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:105 PENN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1020
Practice Address - Country:US
Practice Address - Phone:410-706-5181
Practice Address - Fax:410-706-5103
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32309208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B70671Medicare UPIN
MDG669Medicare PIN