Healthcare Provider Details

I. General information

NPI: 1366538811
Provider Name (Legal Business Name): MONIQUE JEAN CARROLL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 OLYMPIC ST
SPRINGFIELD OR
97477-3413
US

IV. Provider business mailing address

2073 OLYMPIC ST
SPRINGFIELD OR
97477-3413
US

V. Phone/Fax

Practice location:
  • Phone: 541-682-3550
  • Fax: 541-682-6703
Mailing address:
  • Phone: 541-682-3550
  • Fax: 541-682-6703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO27714
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: