Provider Demographics
NPI:1144506171
Name:CARROLL, OLGA B (AA)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:B
Last Name:CARROLL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:OLGA
Other - Middle Name:
Other - Last Name:BERNSTEYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5432 LONDON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5397
Mailing Address - Country:US
Mailing Address - Phone:904-210-6954
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006235367H00000X
FLAA124367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG01UTOtherBCBS
FL014251100Medicaid
FLIA667ZMedicare PIN