Healthcare Provider Details

I. General information

NPI: 1669532008
Provider Name (Legal Business Name): STEPHEN BRENT CARROLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 THE 25 WAY NE SUITE 150
ALBUQUERQUE NM
87109-5857
US

IV. Provider business mailing address

4411 THE 25 WAY NE SUITE 150
ALBUQUERQUE NM
87109-5857
US

V. Phone/Fax

Practice location:
  • Phone: 505-332-6919
  • Fax: 505-332-6921
Mailing address:
  • Phone: 505-332-6919
  • Fax: 505-332-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME160184
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.134086
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD2013-0668
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA83492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: