Provider Demographics
NPI:1083864474
Name:MARIO E CARBONELL MD PA
Entity Type:Organization
Organization Name:MARIO E CARBONELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:941-766-1001
Mailing Address - Street 1:17912 TOLDEO BLADE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1042
Mailing Address - Country:US
Mailing Address - Phone:941-766-1001
Mailing Address - Fax:941-766-1830
Practice Address - Street 1:17912 TOLDEO BLADE BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1042
Practice Address - Country:US
Practice Address - Phone:941-766-1001
Practice Address - Fax:941-766-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065067207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375926100Medicaid
FLF89125Medicare UPIN
FL375926100Medicaid