Provider Demographics
NPI:1508936949
Name:MARIA, CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:MARIA
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:PO BOX 17774
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7774
Mailing Address - Country:US
Mailing Address - Phone:904-347-2773
Mailing Address - Fax:904-347-2773
Practice Address - Street 1:4500 HODGES BLVD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2207
Practice Address - Country:US
Practice Address - Phone:904-347-2773
Practice Address - Fax:904-347-2773
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057100174400000X, 208000000X
FLME 112541208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006488800Medicaid