Provider Demographics
NPI:1659363471
Name:CARABALLO, SALLY (DPM)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:CARABALLO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 N CENTRAL AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5087
Mailing Address - Country:US
Mailing Address - Phone:937-878-2800
Mailing Address - Fax:937-878-7261
Practice Address - Street 1:55 N CENTRAL AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5087
Practice Address - Country:US
Practice Address - Phone:937-878-2800
Practice Address - Fax:937-878-7261
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2815213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173726Medicaid
OHU57977Medicare UPIN
OH0787463Medicare ID - Type Unspecified