Provider Demographics
NPI:1366968463
Name:JOHNATHAN CARROLL O.D. PLLC
Entity type:Organization
Organization Name:JOHNATHAN CARROLL O.D. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:512-898-9995
Mailing Address - Street 1:2681 GATTIS SCHOOL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2057
Mailing Address - Country:US
Mailing Address - Phone:512-898-9995
Mailing Address - Fax:512-898-9994
Practice Address - Street 1:2681 GATTIS SCHOOL RD STE 100
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2057
Practice Address - Country:US
Practice Address - Phone:512-898-9995
Practice Address - Fax:512-898-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8104TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty