Healthcare Provider Details

I. General information

NPI: 1891130829
Provider Name (Legal Business Name): WILLIAM JESSUP CARROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 HIGHWAY 81
LOGANVILLE GA
30052-4336
US

IV. Provider business mailing address

3535 HIGHWAY 81
LOGANVILLE GA
30052-4336
US

V. Phone/Fax

Practice location:
  • Phone: 770-520-8303
  • Fax: 478-500-8205
Mailing address:
  • Phone: 770-520-8303
  • Fax: 478-500-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number91276
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number91276
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: