Provider Demographics
NPI:1679897102
Name:CARROLL, BENJAMIN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:PATRICK
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 LOMITA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5002
Mailing Address - Country:US
Mailing Address - Phone:310-517-4759
Mailing Address - Fax:
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-517-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118743207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program