Provider Demographics
NPI:1366492845
Name:CARBALLOSA, MARIA ANTONIETA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ANTONIETA
Last Name:CARBALLOSA
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 1:4395 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4014
Mailing Address - Country:US
Mailing Address - Phone:305-821-3944
Mailing Address - Fax:305-821-4301
Practice Address - Street 1:4395 PALM AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4014
Practice Address - Country:US
Practice Address - Phone:305-821-3944
Practice Address - Fax:305-821-4301
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59149208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056791400Medicaid
FL056791400Medicaid