Provider Demographics
NPI:1700179884
Name:CARBONELLO, JUSTIN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:CARBONELLO
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 1:135 LEONARD ST
Mailing Address - Street 2:APT 3
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-3101
Mailing Address - Country:US
Mailing Address - Phone:973-975-7527
Mailing Address - Fax:
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:973-975-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09852000207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program