Healthcare Provider Details

I. General information

NPI: 1790167799
Provider Name (Legal Business Name): CRISTIAN CARBUCCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 UPPER RIVERDALE RD SW STE 10
RIVERDALE GA
30274
US

IV. Provider business mailing address

4422 THIRD AVE MILLS BLDG 3RD, DEPT OF INTERNAL MEDICINE
BRONX NY
10457-2545
US

V. Phone/Fax

Practice location:
  • Phone: 770-897-7043
  • Fax:
Mailing address:
  • Phone: 718-960-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number80551
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: