Provider Demographics
NPI:1124249677
Name:CARBALLO-RIVERA, LOURDES (MD)
Entity type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:
Last Name:CARBALLO-RIVERA
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 1:224 CALLE VIENA
Mailing Address - Street 2:URB. COLLEGE PARK 4
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-4804
Mailing Address - Country:US
Mailing Address - Phone:787-758-0898
Mailing Address - Fax:
Practice Address - Street 1:224 CALLE VIENA
Practice Address - Street 2:URB. COLLEGE PARK 4
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-4804
Practice Address - Country:US
Practice Address - Phone:787-758-0898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR38862084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry