Healthcare Provider Details

I. General information

NPI: 1558307835
Provider Name (Legal Business Name): EFREN CARBONELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CECIL G COSTIN SR BLVD
PORT ST JOE FL
32456-1928
US

IV. Provider business mailing address

403 E 11TH ST
PANAMA CITY FL
32401-3409
US

V. Phone/Fax

Practice location:
  • Phone: 850-229-1043
  • Fax: 850-229-1104
Mailing address:
  • Phone: 850-747-5599
  • Fax: 850-872-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12359
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN262
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12359
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: