Provider Demographics
NPI:1841298262
Name:CARBAJAL, SCOTT A (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:CARBAJAL
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 1:555 E. CHEVES ST.
Mailing Address - Street 2:ATTN RADIOLOGY DEPARTMENT
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2617
Mailing Address - Country:US
Mailing Address - Phone:843-777-2879
Mailing Address - Fax:
Practice Address - Street 1:1800 RYAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-6078
Practice Address - Country:US
Practice Address - Phone:337-439-4706
Practice Address - Fax:337-439-8110
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023592174400000X
LAMD.0235922085R0202X
MS192622085R0202X
SC276132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1483451Medicaid
LAG83670Medicare UPIN
LA5A979Medicare PIN