Healthcare Provider Details

I. General information

NPI: 1104055730
Provider Name (Legal Business Name): NICK CARROLL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 E 81ST ST STE 400
TULSA OK
74137-4294
US

IV. Provider business mailing address

7912 E. 31ST COURT
TULSA OK
74145-1334
US

V. Phone/Fax

Practice location:
  • Phone: 918-710-4222
  • Fax: 539-867-3947
Mailing address:
  • Phone: 918-743-8200
  • Fax: 918-743-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4745
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: