Provider Demographics
NPI:1598852428
Name:CARROLL, TIMOTHY GLENN (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GLENN
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 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:8331 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6094
Practice Address - Country:US
Practice Address - Phone:850-505-4700
Practice Address - Fax:850-505-4711
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK283462080P0203X
FLME1588622080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ141276Medicare PIN