Provider Demographics
NPI:1598146474
Name:HECTOR L DI CARLO MD PA
Entity Type:Organization
Organization Name:HECTOR L DI CARLO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:DI CARLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-533-1173
Mailing Address - Street 1:500 SE 17TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2547
Mailing Address - Country:US
Mailing Address - Phone:954-533-1173
Mailing Address - Fax:
Practice Address - Street 1:500 SE 17TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2547
Practice Address - Country:US
Practice Address - Phone:954-533-1173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102570207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0011234400Medicaid
FLAU052SMedicare UPIN