Provider Demographics
NPI:1083153761
Name:CARMONA, JUAN ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ANTONIO
Last Name:CARMONA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2307 BOLADO PKWY
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2712
Mailing Address - Country:US
Mailing Address - Phone:239-297-9730
Mailing Address - Fax:239-257-3827
Practice Address - Street 1:2307 BOLADO PKWY
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2712
Practice Address - Country:US
Practice Address - Phone:239-424-8122
Practice Address - Fax:239-257-3827
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19664207Q00000X
FLACN962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine