Healthcare Provider Details

I. General information

NPI: 1336133768
Provider Name (Legal Business Name): BRIAN DAVID O'CARROLL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 OAK PARK BLVD STE 106
PISMO BEACH CA
93449-3406
US

IV. Provider business mailing address

911 OAK PARK BLVD STE 106
PISMO BEACH CA
93449-3406
US

V. Phone/Fax

Practice location:
  • Phone: 805-481-9100
  • Fax: 805-481-9199
Mailing address:
  • Phone: 805-481-9100
  • Fax: 805-481-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: