Healthcare Provider Details

I. General information

NPI: 1649482936
Provider Name (Legal Business Name): KENNETH J CARBONE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 CENTER RD SUITE A
AVON OH
44011-1239
US

IV. Provider business mailing address

PO BOX 636643
CINCINNATI OH
45263-6643
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-4600
  • Fax: 440-937-4605
Mailing address:
  • Phone: 440-989-3801
  • Fax: 440-960-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34004186
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: