Provider Demographics
NPI:1740216076
Name:CARBALLO, CRISTINA (MD)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:CARBALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CLARENDON AVE
Mailing Address - Street 2:375
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3420
Mailing Address - Country:US
Mailing Address - Phone:602-277-4161
Mailing Address - Fax:602-274-3394
Practice Address - Street 1:300 W CLARENDON AVE
Practice Address - Street 2:375
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3420
Practice Address - Country:US
Practice Address - Phone:602-277-4161
Practice Address - Fax:602-274-3394
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17875208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ279126Medicaid