Provider Demographics
NPI:1891058335
Name:CARBALLO MADRIGAL, FABIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FABIAN
Middle Name:
Last Name:CARBALLO MADRIGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FABIAN
Other - Middle Name:
Other - Last Name:CARBALLO MADRIGAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0325
Mailing Address - Fax:
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY STE 1200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3826
Practice Address - Country:US
Practice Address - Phone:502-588-2160
Practice Address - Fax:502-588-2161
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP426207XS0117X
KY45220207XS0117X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201109750Medicaid
KY7100226970Medicaid
KY775158OtherANTHEM- NLSC
KYK052580OtherMEDICARE- NORTON LEATHERMAN SPINE