Provider Demographics
NPI:1164488540
Name:JORGE CARABALLO, JOSUE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSUE
Middle Name:
Last Name:JORGE CARABALLO
Suffix:
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 1:480 W LOWDER ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2664
Mailing Address - Country:US
Mailing Address - Phone:904-259-6291
Mailing Address - Fax:904-259-4761
Practice Address - Street 1:480 W LOWDER ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2664
Practice Address - Country:US
Practice Address - Phone:904-259-6291
Practice Address - Fax:904-259-4761
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15568208D00000X
FLACN275208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI32365Medicare UPIN
PR23206Medicare ID - Type Unspecified