Provider Demographics
NPI:1841655784
Name:CARRASQUILLA, TATIANA (MD)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:CARRASQUILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 DAUPHIN ISLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36605-3472
Mailing Address - Country:US
Mailing Address - Phone:251-445-3459
Mailing Address - Fax:
Practice Address - Street 1:2601 DAUPHIN ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36605-3472
Practice Address - Country:US
Practice Address - Phone:251-445-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.073796208D00000X
390200000X
AL43960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program