Provider Demographics
NPI:1770792384
Name:CARBONARA, DAVID MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:CARBONARA
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SOUTHPARK BLVD STE B201
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5159
Mailing Address - Country:US
Mailing Address - Phone:904-824-1636
Mailing Address - Fax:
Practice Address - Street 1:105 SOUTHPARK BLVD STE B201
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5159
Practice Address - Country:US
Practice Address - Phone:904-824-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FL28217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist