Provider Demographics
NPI:1508125907
Name:CARABALLO, JUAN C (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:CARABALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:CARABALLO FONSECA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1900 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2200
Mailing Address - Country:US
Mailing Address - Phone:319-471-5877
Mailing Address - Fax:
Practice Address - Street 1:1900 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2200
Practice Address - Country:US
Practice Address - Phone:319-471-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA137119207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program