Provider Demographics
NPI:1437186566
Name:CARBALLIDO, JORGE
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:CARBALLIDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARR #19 GARDEN HILL PLAZA 1353
Mailing Address - Street 2:PMB 228
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-793-5874
Mailing Address - Fax:
Practice Address - Street 1:CARR #19 GARDEN HILL PLAZA 1353
Practice Address - Street 2:PMB 228
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-793-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12939208D00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0083658Medicare ID - Type Unspecified
PRG04571Medicare UPIN