Provider Demographics
NPI:1780681239
Name:CARROLL, CHARLES PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:89 SYLVANIA DR
Mailing Address - Street 2:2ND FL
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3237
Mailing Address - Country:US
Mailing Address - Phone:937-427-8900
Mailing Address - Fax:937-427-1710
Practice Address - Street 1:89 SYLVANIA DR
Practice Address - Street 2:2ND FL
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-3237
Practice Address - Country:US
Practice Address - Phone:937-427-8900
Practice Address - Fax:937-427-1710
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038423207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0436415Medicaid
OHCA0455642Medicare PIN
0802203OtherEVERCARE
OH0436415Medicaid
000000011285OtherBC/BS
315875449OtherMEDICAL MUTUAL
CO1590Medicare UPIN
010019152Medicare PIN
314082OtherAMERIGROUP
1904161001OtherCIGNA
OHCA0455642Medicare PIN
311011691026OtherCARESOURCE
0801094OtherUNITED HEALTHCARE