Provider Demographics
NPI:1689825358
Name:JUAN J CARRERE MD LLC
Entity Type:Organization
Organization Name:JUAN J CARRERE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARRERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-913-1440
Mailing Address - Street 1:1633 TREASURE LK
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-9043
Mailing Address - Country:US
Mailing Address - Phone:814-913-1440
Mailing Address - Fax:814-913-1440
Practice Address - Street 1:13710 METROPOLIS AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7144
Practice Address - Country:US
Practice Address - Phone:239-415-2273
Practice Address - Fax:239-415-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85054261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAQ777OtherMEDICARE PTAN
FLDO8380OtherRAILROAD MEDICARE