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1629029749 NPI number — EDMUND THOMAS CARROLL III D.O.

NPI Number: 1629029749
Health Care Provider/Practitioner: EDMUND THOMAS CARROLL III D.O.

Information about “1629029749” NPI (EDMUND THOMAS CARROLL III D.O.) exists in 1629029749 in HTML format HTML  |  1629029749 in plain Text format TXT  |  1629029749 in PDF (Portable Document Format) PDF  |  1629029749 in an XML format XML  formats.

NPI Number : 1629029749 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1629029749",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CARROLL",
    "FirstName": "EDMUND",
    "MiddleName": "THOMAS",
    "NamePrefix": "DR.",
    "NameSuffix": "III",
    "Credential": "D.O.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "211 EXECUTIVE DR STE 11",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "NEWARK",
    "MailingAddressStateName": "DE",
    "MailingAddressPostalCode": "19702-3358",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "302-451-6913",
    "MailingAddressFaxNumber": "302-368-7756",
    "FirstLinePracticeLocationAddress": "12100 BLACK SWAN DRIVE",
    "SecondLinePracticeLocationAddress": "SUITE 201",
    "PracticeLocationAddressCityName": "LEWES",
    "PracticeLocationAddressStateName": "DE",
    "PracticeLocationAddressPostalCode": "19958-4988",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "302-644-3311",
    "PracticeLocationAddressFaxNumber": "302-644-3300",
    "EnumerationDate": "05/13/2006",
    "LastUpdateDate": "01/23/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "207X00000X",
        "TaxonomyName": "Orthopaedic Surgery Physician",
        "LicenseNumber": "C20007511",
        "LicenseNumberStateCode": "DE",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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