Provider Demographics
NPI:1386875896
Name:MARIO CARCAMO PA
Entity type:Organization
Organization Name:MARIO CARCAMO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:CARCAMO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-662-2990
Mailing Address - Street 1:7795 W FLAGLER ST
Mailing Address - Street 2:#63
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2359
Mailing Address - Country:US
Mailing Address - Phone:305-662-2990
Mailing Address - Fax:305-380-7106
Practice Address - Street 1:7795 W FLAGLER ST
Practice Address - Street 2:#63
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2368
Practice Address - Country:US
Practice Address - Phone:305-662-2990
Practice Address - Fax:305-380-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078938100Medicaid
FL078938100Medicaid
FL20429Medicare PIN