Provider Demographics
NPI:1568654101
Name:ANTOLA LARDIZABAL, CARLA (MD)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:ANTOLA LARDIZABAL
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 1:1608 SE 3RD AVE
Mailing Address - Street 2:THIRD FLOOR PBO
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 N COMMERCE PARKWAY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-217-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124251207Q00000X
ORMD150544207Q00000X
MI4301090806207Q00000X
FLME126706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME126706OtherMEDICAL LICENSE
OR161133OtherNBMC GROUP MEDICAID
MI4301090806OtherSTATE LICENCE
ORR0000WFBTVOtherNBMC GROUP MEDICARE
ORMD150544OtherOREGON MEDICAL LICENSE
FLME126706OtherMEDICAL LICENSE