Provider Demographics
NPI:1295875854
Name:CARROLL, ROBERT MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MATTHEW
Last Name:CARROLL
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 1:20162 SW BIRCH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-0787
Mailing Address - Country:US
Mailing Address - Phone:949-553-3330
Mailing Address - Fax:949-631-9012
Practice Address - Street 1:20162 SW BIRCH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-0787
Practice Address - Country:US
Practice Address - Phone:949-553-3330
Practice Address - Fax:949-631-9012
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69851207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A698510OtherBLUESHIELD OF CALIFORNIA
CAAETNAOther7861689
CAWA69851AOtherMEDICARE PPIN
CAI37037Medicare UPIN
CAAETNAOther7861689