Provider Demographics
NPI:1639150048
Name:CARBONELL, MARIO E (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:CARBONELL
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 1:17912 TOLEDO BLADE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1042
Mailing Address - Country:US
Mailing Address - Phone:941-766-1001
Mailing Address - Fax:941-766-1830
Practice Address - Street 1:17912 TOLEDO BLADE BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1042
Practice Address - Country:US
Practice Address - Phone:941-766-1001
Practice Address - Fax:941-766-1830
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065067207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375926100Medicaid
FL25824AMedicare ID - Type Unspecified
FL375926100Medicaid