Healthcare Provider Details

I. General information

NPI: 1770134231
Provider Name (Legal Business Name): SAMIRA CARABALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W EAU GALLIE BLVD
MELBOURNE FL
32935-5958
US

IV. Provider business mailing address

1420 NE MIAMI PL APT 1611
MIAMI FL
33132-1355
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-3223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberPA9112599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: