Provider Demographics
NPI:1609896687
Name:CARBALLO, JORGE LUIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:CARBALLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CAMILO AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-7207
Mailing Address - Country:US
Mailing Address - Phone:305-642-4777
Mailing Address - Fax:305-642-0600
Practice Address - Street 1:1330 SW 22ND ST STE 408
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2945
Practice Address - Country:US
Practice Address - Phone:305-642-4777
Practice Address - Fax:305-642-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002773213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340052200Medicaid
FLE2480DMedicare PIN
FLU74991Medicare UPIN