Provider Demographics
NPI:1124229786
Name:CARBALLO, LARA V (RPT)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:V
Last Name:CARBALLO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:BOUFFARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2739 UPPER PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6148
Mailing Address - Country:US
Mailing Address - Phone:407-443-9696
Mailing Address - Fax:407-754-2624
Practice Address - Street 1:2739 UPPER PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6148
Practice Address - Country:US
Practice Address - Phone:407-443-9696
Practice Address - Fax:407-754-2624
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT136752251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics