Provider Demographics
NPI:1902893720
Name:CARROLL, KIM (DPM)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ENTERPRIZE PKWY
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-4118
Mailing Address - Country:US
Mailing Address - Phone:361-939-6510
Mailing Address - Fax:361-939-6511
Practice Address - Street 1:205 S ENTERPRIZE PKWY
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-4118
Practice Address - Country:US
Practice Address - Phone:361-939-6510
Practice Address - Fax:361-939-6511
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC498213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC081A1OtherBCBS OF NC
NC5902315Medicaid
NCP00634269OtherRAILROAD MEDICARE
V07477Medicare UPIN
NC5902315Medicaid