Provider Demographics
NPI:1013304179
Name:CARRASQUILLO MONTALVO, SEBASTIAN
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:CARRASQUILLO MONTALVO
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 1:3901 UNIVERSITY BLVD S STE 221
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4392
Mailing Address - Country:US
Mailing Address - Phone:904-244-3066
Mailing Address - Fax:
Practice Address - Street 1:3901 UNIVERSITY BLVD S STE 221
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4392
Practice Address - Country:US
Practice Address - Phone:904-423-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME154070207RI0011X
FLME154707207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program