Provider Demographics
NPI:1821104613
Name:RAUL E. CARBALLOSA AND ASSOCIATESMDSPA
Entity Type:Organization
Organization Name:RAUL E. CARBALLOSA AND ASSOCIATESMDSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILIING SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-639-4933
Mailing Address - Street 1:PO BOX 510730
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0730
Mailing Address - Country:US
Mailing Address - Phone:941-639-4933
Mailing Address - Fax:
Practice Address - Street 1:310 DUPONT ST
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3810
Practice Address - Country:US
Practice Address - Phone:941-639-4933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047929174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11726OtherBLUE CROSS BLUE SHIELD
FLE73093Medicare UPIN
FL11726ZMedicare PIN