Healthcare Provider Details

I. General information

NPI: 1487093399
Provider Name (Legal Business Name): DANIEL JOHN-MARTIN CARROLL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 03/07/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7388 BUSINESS CENTER DR
AVON IN
46123-6973
US

IV. Provider business mailing address

10001 W INNOVATION DR STE 200
MILWAUKEE WI
53226-4851
US

V. Phone/Fax

Practice location:
  • Phone: 888-938-3838
  • Fax: 888-919-1083
Mailing address:
  • Phone: 888-938-3838
  • Fax: 888-919-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number64776
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01092672A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: