Provider Demographics
NPI:1154409464
Name:CARBONELL, ALFREDO MAXIMILIANO II (DO)
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:MAXIMILIANO
Last Name:CARBONELL
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:2104 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5941
Practice Address - Country:US
Practice Address - Phone:864-676-1072
Practice Address - Fax:864-676-0729
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1102208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC011025Medicaid
SCP00452985OtherRR MEDICARE
SCAA2358Medicare PIN
SCAA23587951Medicare PIN
SCAA23586904Medicare PIN