Provider Demographics
NPI:1427010362
Name:CARBALLO, FERNANDO A (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:A
Last Name:CARBALLO
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:8380 RIVERWALK PARK BLVD STE 310
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8758
Practice Address - Country:US
Practice Address - Phone:239-291-3602
Practice Address - Fax:239-291-3603
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53132207RG0100X
FLME137751207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00742968OtherRR MEDICARE
WI32471200Medicaid
WI32471200Medicaid
WI01994-0388Medicare PIN
WIP00742968OtherRR MEDICARE