Provider Demographics
NPI:1205330875
Name:CARROLL, CORY ROBERT (DO)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:ROBERT
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 1:1222 S ORANGE AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-1692
Mailing Address - Fax:321-843-1791
Practice Address - Street 1:1222 S ORANGE AVE FL 5
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-1692
Practice Address - Fax:321-843-1791
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS18677207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program