Provider Demographics
NPI:1740399799
Name:CARCAMO, ANTONIO DE JESUS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:DE JESUS
Last Name:CARCAMO
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 2442
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33836-2442
Mailing Address - Country:US
Mailing Address - Phone:863-204-9485
Mailing Address - Fax:863-204-9015
Practice Address - Street 1:2320 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8998
Practice Address - Country:US
Practice Address - Phone:863-204-9485
Practice Address - Fax:863-204-9015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278948500Medicaid
FL56596OtherBCBS