Provider Demographics
NPI:1992164230
Name:CARABALLO RIVERA, KATHY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:ANN
Last Name:CARABALLO RIVERA
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:PO BOX 1757
Mailing Address - Street 2:
Mailing Address - City:UTUADO
Mailing Address - State:PR
Mailing Address - Zip Code:00641-1757
Mailing Address - Country:US
Mailing Address - Phone:787-201-9026
Mailing Address - Fax:
Practice Address - Street 1:CARR #2 KM 11.7
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-201-9026
Practice Address - Fax:787-621-3553
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR32243R208D00000X
PR19408208D00000X, 207Q00000X
PR13519I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program