Provider Demographics
NPI:1962130815
Name:CARVAJAL, HECTOR R
Entity type:Individual
Prefix:
First Name:HECTOR
Middle Name:R
Last Name:CARVAJAL
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 1:8650 SW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1006
Mailing Address - Country:US
Mailing Address - Phone:786-501-0403
Mailing Address - Fax:
Practice Address - Street 1:12030 SW 129TH CT STE 211
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4584
Practice Address - Country:US
Practice Address - Phone:305-639-8760
Practice Address - Fax:786-953-5144
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM.0102758171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator