Provider Demographics
NPI:1962464461
Name:CARABALLO, ULISES MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:ULISES
Middle Name:MANUEL
Last Name:CARABALLO
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:1201 MONUMENT RD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7428
Practice Address - Country:US
Practice Address - Phone:904-727-5151
Practice Address - Fax:904-727-5180
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061247200Medicaid
FL061247200Medicaid
FL09290XMedicare PIN