Provider Demographics
NPI:1619218740
Name:CEBOLLERO, CARLOS JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JOSE
Last Name:CEBOLLERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CARLOS
Other - Middle Name:J
Other - Last Name:CEBOLLERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1300 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5054
Mailing Address - Country:US
Mailing Address - Phone:850-431-1155
Mailing Address - Fax:850-431-6975
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-431-1155
Practice Address - Fax:850-431-6975
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293845-1207R00000X
PR19186207R00000X
FL140844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty