Healthcare Provider Details

I. General information

NPI: 1831162221
Provider Name (Legal Business Name): BRIAN KEITH CARREON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 12TH ST SUITE A
SHALLOWATER TX
79363-5652
US

IV. Provider business mailing address

PO BOX 2088
SHALLOWATER TX
79363-2088
US

V. Phone/Fax

Practice location:
  • Phone: 806-832-4566
  • Fax: 806-832-4143
Mailing address:
  • Phone: 806-832-4566
  • Fax: 806-832-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL9125
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL9125
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: