Provider Demographics
NPI:1265796049
Name:FRY, CARL R (DO)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:R
Last Name:FRY
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 1:1020 TRUMP RD NW STE 4
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-8423
Mailing Address - Country:US
Mailing Address - Phone:330-627-0884
Mailing Address - Fax:330-627-0885
Practice Address - Street 1:1020 TRUMP RD NW STE 4
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-8423
Practice Address - Country:US
Practice Address - Phone:330-627-0884
Practice Address - Fax:330-627-0885
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121584Medicaid