Provider Demographics
NPI:1790821122
Name:CARROLL, RONALD EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EUGENE
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 1:823 CENTER AVE
Mailing Address - Street 2:P.O. BOX 175
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2535
Mailing Address - Country:US
Mailing Address - Phone:208-642-3396
Mailing Address - Fax:208-642-9060
Practice Address - Street 1:823 CENTER AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2535
Practice Address - Country:US
Practice Address - Phone:208-642-3396
Practice Address - Fax:208-642-9060
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010005775OtherREGENCE BLUE SHIELD
R108734OtherMEDICARE-NORIDIAN
ID003636500Medicaid
73437OtherBLUE CROSS
820525763OtherCOMMERCIAL
OR231902Medicaid
D80174720OtherMEDICARE- RAILROAD
1129186Medicare PIN