Healthcare Provider Details

I. General information

NPI: 1114927373
Provider Name (Legal Business Name): CHARLES LOYD CARROLL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4778 S SCATTERFIELD RD
ANDERSON IN
46013-2908
US

IV. Provider business mailing address

4778 S SCATTERFIELD RD
ANDERSON IN
46013-2908
US

V. Phone/Fax

Practice location:
  • Phone: 765-646-6331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number02001626A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001626A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02001626A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: