Provider Demographics
NPI:1992728448
Name:CARBALLOSA, RAUL ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:ENRIQUE
Last Name:CARBALLOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9960 NW 116TH WAY
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1167
Mailing Address - Country:US
Mailing Address - Phone:786-924-1311
Mailing Address - Fax:786-924-1313
Practice Address - Street 1:9970 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 207
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2231
Practice Address - Country:US
Practice Address - Phone:561-482-1027
Practice Address - Fax:561-482-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0047929174400000X
FLME479292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053698900Medicaid
FL11726Medicare PIN
FL053698900Medicaid