MEDICARE: DR. JOHN RAYMOND CARROLL MD

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	207Q00000X	Family Medicine Physician	P9312	TX
2	207Q00000X	Family Medicine Physician	22136	IA
3	207QG0300X	Geriatric Medicine (Family Medicine) Physician	P9312	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1L5224	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P02601758	OTHER	TX	MCRR
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992792881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN RAYMOND CARROLL MD

Provider Business Mailing Address
First Line	:	919 HIDDEN RDG
Second Line	:	6TH FLOOR
City	:	IRVING
State	:	TX
Zip	:	75038-3813
Country	:	US
Telephone Number	:	469-282-2625
Fax Number	:	469-282-2655

Provider Business Practice Location Address
First Line	:	2606 HOSPITAL BLVD STE B
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78405-1804
Country	:	US
Telephone Number	:	469-282-4789
Fax Number	:	469-282-4588

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

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	04/12/2021

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