Healthcare Provider Details

I. General information

NPI: 1902894629
Provider Name (Legal Business Name): GREGORY M CARBONE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax:
Mailing address:
  • Phone: 320-255-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number056692
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200300010
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number735
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0102201824
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number200300010
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: