Provider Demographics
NPI:1992792881
Name:CARROLL, JOHN RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAYMOND
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2625
Mailing Address - Fax:469-282-2655
Practice Address - Street 1:2606 HOSPITAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1804
Practice Address - Country:US
Practice Address - Phone:469-282-4789
Practice Address - Fax:469-282-4588
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9312207Q00000X, 207QG0300X
IA22136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1L5224OtherMEDICARE
TXP02601758OtherMCRR
IA2196766Medicaid
TX332933605Medicaid
TX332933601Medicaid