Provider Demographics
NPI:1457192486
Name:BECERRA CARBALLO, WILBERT
Entity type:Individual
Prefix:
First Name:WILBERT
Middle Name:
Last Name:BECERRA CARBALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2169
Mailing Address - Country:US
Mailing Address - Phone:786-879-4409
Mailing Address - Fax:
Practice Address - Street 1:JACKSON SOUTH MEDICAL CENTER
Practice Address - Street 2:9333 SW 152 ST
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:305-256-5237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE24381208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist