Provider Demographics
NPI:1649598111
Name:RENALDO, CARLA ROCHELLE (DO)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:ROCHELLE
Last Name:RENALDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:727-581-8767
Mailing Address - Fax:727-588-9478
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-581-8767
Practice Address - Fax:727-588-9478
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-09
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12089207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009258700Medicaid
FL14R7JOtherBLUE CROSS BLUE SHIELD