Provider Demographics
NPI:1043736176
Name:BACALLAO, CARLOS A (ARNP)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:BACALLAO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2211
Mailing Address - Country:US
Mailing Address - Phone:305-823-3312
Mailing Address - Fax:305-884-3989
Practice Address - Street 1:704 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6012
Practice Address - Country:US
Practice Address - Phone:305-250-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9271517363LA2200X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty