Provider Demographics
NPI:1467476788
Name:CARROLL, IVAN DALE (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:DALE
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 1:17720 COBBLEFIELD LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9264
Mailing Address - Country:US
Mailing Address - Phone:616-296-0622
Mailing Address - Fax:
Practice Address - Street 1:17720 COBBLEFIELD LN
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9264
Practice Address - Country:US
Practice Address - Phone:616-296-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010369382083P0901X, 207V00000X
MI5315171197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4282462Medicaid
MIA78437Medicare UPIN
MI231858Medicare Oscar/Certification
MI4282462Medicaid