Provider Demographics
NPI:1679562730
Name:CARROLL, DAVID ROLAND (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROLAND
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 656
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-366-6606
Mailing Address - Fax:601-366-6647
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 656
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-366-6606
Practice Address - Fax:601-366-6647
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16117208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120078Medicaid
MS020000345Medicare ID - Type Unspecified
MS00120078Medicaid