Provider Demographics
NPI:1932276227
Name:CARRELL, TODD A (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:CARRELL
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 1:532 OREGON ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3254
Mailing Address - Country:US
Mailing Address - Phone:707-649-4007
Mailing Address - Fax:707-649-4077
Practice Address - Street 1:532 OREGON ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3254
Practice Address - Country:US
Practice Address - Phone:707-649-4007
Practice Address - Fax:707-649-4077
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA502502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A502500Medicaid
CA00A502500Medicaid
CAE43905Medicare UPIN