Healthcare Provider Details

I. General information

NPI: 1366492845
Provider Name (Legal Business Name): MARIA ANTONIETA CARBALLOSA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4395 PALM AVE
HIALEAH FL
33012-4014
US

IV. Provider business mailing address

4395 PALM AVE
HIALEAH FL
33012-4014
US

V. Phone/Fax

Practice location:
  • Phone: 305-821-3944
  • Fax: 305-821-4301
Mailing address:
  • Phone: 305-821-3944
  • Fax: 305-821-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME59149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: