Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080N0001X | Neonatal-Perinatal Doctor | 074111 | GA |
N | 2080N0001X | Neonatal-Perinatal Doctor | N5608 | TX |
NPI | 1114137551 |
---|---|
Provider Name | Dr. Travis Rod Carroll |
First Address | Dalton, GA 30722-2645 |
Second Address | Dalton, GA 30720-2529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 12/01/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003161386A | (05) | GA |
213538601 | (05) | TX |