Healthcare Provider Details

I. General information

NPI: 1679562730
Provider Name (Legal Business Name): DAVID ROLAND CARROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR SUITE 656
JACKSON MS
39216-4643
US

IV. Provider business mailing address

971 LAKELAND DR SUITE 656
JACKSON MS
39216-4643
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-6606
  • Fax: 601-366-6647
Mailing address:
  • Phone: 601-366-6606
  • Fax: 601-366-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16117
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: