Healthcare Provider Details

I. General information

NPI: 1154270593
Provider Name (Legal Business Name): EZEQUIEL CARABALLO NIEBLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W OAK ST
KISSIMMEE FL
34741-4931
US

IV. Provider business mailing address

401 W OAK ST
KISSIMMEE FL
34741-4931
US

V. Phone/Fax

Practice location:
  • Phone: 407-674-2044
  • Fax: 407-674-2049
Mailing address:
  • Phone: 407-674-2044
  • Fax: 407-674-2049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1798
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number024806
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: