Provider Demographics
NPI:1487772935
Name:CARROLL, LAWRENCE ALAN (OPTICIAN)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALAN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 SAINT JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4026
Mailing Address - Country:US
Mailing Address - Phone:386-328-2020
Mailing Address - Fax:386-328-6430
Practice Address - Street 1:3710 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4026
Practice Address - Country:US
Practice Address - Phone:386-328-2020
Practice Address - Fax:386-328-6430
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO889156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0865600001Medicare PIN