Provider Demographics
NPI:1396241733
Name:CAROLIN, PHILIP JOHN (DPM)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JOHN
Last Name:CAROLIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3971
Mailing Address - Country:US
Mailing Address - Phone:502-804-4811
Mailing Address - Fax:
Practice Address - Street 1:935 CHAMBERS BLVD UNIT D
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2575
Practice Address - Country:US
Practice Address - Phone:844-692-3338
Practice Address - Fax:502-331-6309
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY269144213ES0103X
IN07001370A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07001370AOtherMEDICAL LICENSE
KY269144OtherMEDICAL LICENSE