Provider Demographics
NPI:1861479628
Name:CARROLL, CRAIG GRASON (DO)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:GRASON
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1694 WATERGLEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-6900
Mailing Address - Country:US
Mailing Address - Phone:757-282-3953
Mailing Address - Fax:
Practice Address - Street 1:1511 ONYX CIR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-7805
Practice Address - Country:US
Practice Address - Phone:303-776-5298
Practice Address - Fax:303-682-2785
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0055838204R00000X
CODR.558382084N0400X
FLOS137332084N0600X
MDH00611182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0055838OtherLICENSE