Provider Demographics
NPI:1104055730
Name:CARROLL, NICK (DO)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7912 E. 31ST COURT
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1334
Mailing Address - Country:US
Mailing Address - Phone:918-743-8200
Mailing Address - Fax:918-743-8609
Practice Address - Street 1:2448 E 81ST ST STE 400
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4294
Practice Address - Country:US
Practice Address - Phone:918-710-4222
Practice Address - Fax:539-867-3947
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200251920AMedicaid
OKOKAAA1461Medicare PIN