Provider Demographics
NPI:1669532008
Name:CARROLL, STEPHEN BRENT (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BRENT
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4411 THE 25 WAY NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-332-6919
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-6919
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1601842085R0202X
OH35.1340862085R0202X
NMMD2013-06682085N0700X
CAA834922085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42482780Medicaid
NM42482780Medicaid