Healthcare Provider Details

I. General information

NPI: 1144580242
Provider Name (Legal Business Name): DANIEL CARBALLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PARKLAWN AVE STE 120
EDINA MN
55435-5660
US

IV. Provider business mailing address

3955 PARKLAWN AVE STE 120
EDINA MN
55435-5660
US

V. Phone/Fax

Practice location:
  • Phone: 952-278-6950
  • Fax: 952-278-6947
Mailing address:
  • Phone: 952-278-6950
  • Fax: 952-278-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59095
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: