Provider Demographics
NPI:1962445890
Name:CARROLL, CHARLES W (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
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:PO BOX 2027
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52244-2027
Mailing Address - Country:US
Mailing Address - Phone:319-339-3855
Mailing Address - Fax:319-358-2737
Practice Address - Street 1:56 CEDAR ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1705
Practice Address - Country:US
Practice Address - Phone:563-886-2195
Practice Address - Fax:563-886-3268
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1252346Medicaid
A03452Medicare UPIN
IA59582Medicare PIN