Provider Demographics
NPI:1891130829
Name:CARROLL, WILLIAM JESSUP (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JESSUP
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 1:2705 JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1208
Mailing Address - Country:US
Mailing Address - Phone:706-543-3200
Mailing Address - Fax:
Practice Address - Street 1:2705 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1208
Practice Address - Country:US
Practice Address - Phone:706-543-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.142862207W00000X
FLME140137207W00000X
GA91276207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003265416AMedicaid
GA003265416BMedicaid
FL102600100Medicaid
GA003265416CMedicaid