Provider Demographics
NPI:1568438984
Name:FASTABEND, CARL P (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:P
Last Name:FASTABEND
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:713-640-5938
Practice Address - Street 1:1920 COUNTRY PLACE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2282
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-25
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU2699207RC0000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1193887Medicaid
LA1193887Medicaid
5J4837460Medicare PIN
060018475Medicare PIN