Provider Demographics
NPI:1659361426
Name:CEBOLLERO, CARLOS M (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:M
Last Name:CEBOLLERO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 78 BOX 2093 APO AP
Mailing Address - Street 2:
Mailing Address - City:FUSSA
Mailing Address - State:JAPAN
Mailing Address - Zip Code:96326-0020
Mailing Address - Country:JP
Mailing Address - Phone:315-227-4853
Mailing Address - Fax:
Practice Address - Street 1:YOKOTA AB
Practice Address - Street 2:
Practice Address - City:FUSSA
Practice Address - State:JAPAN
Practice Address - Zip Code:96328
Practice Address - Country:JP
Practice Address - Phone:315-225-8404
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist