MEDICARE: EZEQUIEL CARABALLO NIEBLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	024806	PR

General Provider Information

NPI Number	:	1154270593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EZEQUIEL CARABALLO NIEBLA MD

Provider Business Mailing Address
First Line	:	4160 HOLSTEIN ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-9214
Country	:	US
Telephone Number	:	407-818-9652
Fax Number	:

Provider Business Practice Location Address
First Line	:	4160 HOLSTEIN ST
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-9214
Country	:	US
Telephone Number	:	407-818-9652
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	02/17/2026

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