Provider Demographics
NPI:1679056865
Name:CARABALLO SOLIS, JOHNATHAN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:ALEXANDER
Last Name:CARABALLO SOLIS
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:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-4066
Mailing Address - Country:US
Mailing Address - Phone:787-901-1714
Mailing Address - Fax:
Practice Address - Street 1:URB. INDUSTRIAL REPARADA 2 396 CALLE DR. LUIS F SALA
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-812-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR222512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program