MEDICARE: TIMOTHY FIELD CARROLL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1528694767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY FIELD CARROLL

Provider Business Mailing Address
First Line	:	3435 DICKASON AVE APT 2616
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4987
Country	:	US
Telephone Number	:	501-545-7355
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 DICKASON AVE APT 2616
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4987
Country	:	US
Telephone Number	:	501-545-7355
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2020
Last Update Date	:	03/19/2020

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