Provider Demographics
NPI:1043508914
Name:CARBONELL MEDICAL CLINIC MD PA
Entity Type:Organization
Organization Name:CARBONELL MEDICAL CLINIC MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-433-6452
Mailing Address - Street 1:426 CASTROVILLE RD.
Mailing Address - Street 2:STE. 3
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5169
Mailing Address - Country:US
Mailing Address - Phone:210-433-6452
Mailing Address - Fax:210-433-6452
Practice Address - Street 1:426 CASTROVILLE RD.
Practice Address - Street 2:STE. 3
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5169
Practice Address - Country:US
Practice Address - Phone:210-433-6452
Practice Address - Fax:210-433-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035092801Medicaid
B21691Medicare UPIN
TX035092801Medicaid