Provider Demographics
NPI:1437124047
Name:POL-CARBALLO, MARIA TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:TERESA
Last Name:POL-CARBALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 BLUE LAGOON DR STE 365
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-7010
Mailing Address - Country:US
Mailing Address - Phone:786-322-7333
Mailing Address - Fax:786-322-7329
Practice Address - Street 1:3520 W 18TH AVE STE 115
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4634
Practice Address - Country:US
Practice Address - Phone:786-837-0897
Practice Address - Fax:786-837-0898
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00606042080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0060604OtherFLORIDA LICENSE
FL372237600Medicaid
FL510422441OtherTAX ID NUMBER
FL510422441OtherTAX ID NUMBER