Provider Demographics
NPI:1457573578
Name:CARROLL, JOHN THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
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 1:412 SASSAFRAS COURT
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015
Mailing Address - Country:US
Mailing Address - Phone:443-512-8729
Mailing Address - Fax:
Practice Address - Street 1:9832 YORK RD
Practice Address - Street 2:SUITE F
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-4936
Practice Address - Country:US
Practice Address - Phone:410-628-1861
Practice Address - Fax:410-628-1862
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH47469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG88556Medicare UPIN