Healthcare Provider Details

I. General information

NPI: 1114587326
Provider Name (Legal Business Name): AXEL JAVIER SANTIAGO CARLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3065
US

IV. Provider business mailing address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3065
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-7000
  • Fax: 866-264-8519
Mailing address:
  • Phone: 863-680-7000
  • Fax: 866-264-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME178769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: