Provider Demographics
NPI:1265433510
Name:CARROLL, DONALD A (OD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:CARROLL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356
Mailing Address - Country:US
Mailing Address - Phone:360-496-5140
Mailing Address - Fax:360-496-6039
Practice Address - Street 1:240 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356
Practice Address - Country:US
Practice Address - Phone:360-496-5140
Practice Address - Fax:360-496-6039
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-09
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
WAOD00000957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020931Medicaid
WA2020931Medicaid
WAT02627Medicare UPIN