Provider Demographics
NPI:1114038726
Name:CARBAJO, ALAN L SR (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:CARBAJO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071
Mailing Address - Country:US
Mailing Address - Phone:248-543-0600
Mailing Address - Fax:248-543-4720
Practice Address - Street 1:1200 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-543-0600
Practice Address - Fax:248-543-4720
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79744Medicare UPIN
OF370787Medicare ID - Type Unspecified