Provider Demographics
NPI:1023119138
Name:CARROL, CLIFFORD (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:CARROL
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 34795
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-4795
Mailing Address - Country:US
Mailing Address - Phone:702-220-9865
Mailing Address - Fax:702-251-8196
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1498
Practice Address - Country:US
Practice Address - Phone:570-253-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153344207RG0100X
NV8160207RG0100X
PAMD476546207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1023119138Medicaid
V105925Medicare PIN
V105925Medicare PIN