Provider Demographics
NPI:1225387798
Name:RAUL E. CARBALLOSA AND ASSOCIATES, M.D'S, P.A.
Entity Type:Organization
Organization Name:RAUL E. CARBALLOSA AND ASSOCIATES, M.D'S, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARBALLOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-391-4549
Mailing Address - Street 1:10405 SW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11760 SW 40TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3582
Practice Address - Country:US
Practice Address - Phone:305-227-7021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47929174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053698900Medicaid