Provider Demographics
NPI:1114137551
Name:CARROLL, TRAVIS ROD (MD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:ROD
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:PO BOX 2645
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-2645
Mailing Address - Country:US
Mailing Address - Phone:706-264-1897
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-264-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN56082080N0001X
GA0741112080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161386AMedicaid
TX213538601Medicaid