Provider Demographics
NPI:1912368838
Name:CARBALLO, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
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 1:5092 GUAVA AVENUE
Mailing Address - Street 2:UNIT 124
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-8320
Mailing Address - Country:US
Mailing Address - Phone:310-893-3256
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:MC 0965
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0965
Practice Address - Country:US
Practice Address - Phone:858-822-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA159630208D00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice