Provider Demographics
NPI:1801828850
Name:CARROLL, LORAINE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LORAINE
Middle Name:LYNN
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 1:1600 N GRAND AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-296-2305
Mailing Address - Fax:719-295-2320
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-296-2305
Practice Address - Fax:719-295-2320
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01369420Medicaid
CA604838OtherBCBS
CO01369420Medicaid