Provider Demographics
NPI:1316178916
Name:CARABALLO, JAVIER ALEXIS (MD)
Entity type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:ALEXIS
Last Name:CARABALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2108 CALLE BARONESA
Mailing Address - Street 2:VALLE REAL
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716-0514
Mailing Address - Country:US
Mailing Address - Phone:787-608-3537
Mailing Address - Fax:
Practice Address - Street 1:909 AVE TITO CASTRO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4728
Practice Address - Country:US
Practice Address - Phone:787-651-1435
Practice Address - Fax:787-651-6362
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17686208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17686Medicaid