Provider Demographics
NPI:1962473389
Name:DICARLO, CARLTON (PA)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:
Last Name:DICARLO
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-8371
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-8371
Practice Address - Fax:386-325-1086
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290235400Medicaid