Basic Information
| Provider Information | |||||||||
| NPI: | 1376557199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 EAST MAIN STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLINTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064132058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606696156 | ||||||||
| FaxNumber: | 8606640285 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 EAST MAIN STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLINTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064132058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606696156 | ||||||||
| FaxNumber: | 8606640285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | CT034871 | CT | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | CT034871 | CT | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 001348714 | 05 | CT | MEDICAID |