Provider Demographics
NPI:1295705119
Name:CARBONELL, FABIAN (MD)
Entity type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:CARBONELL
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 1:2845 N SHERIDAN RD STE 708
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7227
Mailing Address - Country:US
Mailing Address - Phone:773-649-4261
Mailing Address - Fax:872-243-2843
Practice Address - Street 1:2845 N SHERIDAN RD STE 708
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7227
Practice Address - Country:US
Practice Address - Phone:773-649-4261
Practice Address - Fax:872-243-2843
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360980282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098028Medicaid
ILG22941Medicare UPIN