Provider Demographics
NPI:1427060276
Name:CARROLL, CORY DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:DOUGLAS
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 1:1032 LUKE ST 2
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4037
Mailing Address - Country:US
Mailing Address - Phone:970-221-5858
Mailing Address - Fax:
Practice Address - Street 1:1032 LUKE ST 2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4037
Practice Address - Country:US
Practice Address - Phone:970-221-5858
Practice Address - Fax:970-484-7191
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01302538Medicaid
CO01302538Medicaid
COC16221Medicare PIN