Provider Demographics
NPI:1821596479
Name:CARBALLO, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CARBALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 SW 41ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5437
Mailing Address - Country:US
Mailing Address - Phone:786-416-1663
Mailing Address - Fax:
Practice Address - Street 1:8710 SW 41ST TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5437
Practice Address - Country:US
Practice Address - Phone:786-416-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9351651163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice