Healthcare Provider Details

I. General information

NPI: 1629122791
Provider Name (Legal Business Name): NINA M CARROLL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 POND AVE
BROOKLINE MA
02445-7170
US

IV. Provider business mailing address

55 POND AVE
BROOKLINE MA
02445-7170
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-0202
  • Fax:
Mailing address:
  • Phone: 617-232-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number57518
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: