Healthcare Provider Details

I. General information

NPI: 1841298262
Provider Name (Legal Business Name): SCOTT A CARBAJAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RYAN ST SUITE 105
LAKE CHARLES LA
70601-6078
US

IV. Provider business mailing address

555 E. CHEVES ST. ATTN RADIOLOGY DEPARTMENT
FLORENCE SC
29506-2617
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-4706
  • Fax: 337-439-8110
Mailing address:
  • Phone: 843-777-2879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number023592
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.023592
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19262
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number27613
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: