Provider Demographics
NPI:1366580532
Name:CARROLL, CHRISTIE LYN (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIE
Middle Name:LYN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:CHRISTIE
Other - Middle Name:L
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORCOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5169
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-669-3638
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97679207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00745222OtherMEDICARE RAILROAD CARRIER
CAP00745222OtherMEDICARE RAILROAD CARRIER