Healthcare Provider Details

I. General information

NPI: 1023139896
Provider Name (Legal Business Name): SIMON E. CARLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 SAN JORGE ST. SUITE 408
SANTURCE PR
00912
US

IV. Provider business mailing address

PO BOX 911
CABO ROJO PR
00623-0911
US

V. Phone/Fax

Practice location:
  • Phone: 787-728-8316
  • Fax: 787-728-8316
Mailing address:
  • Phone: 787-635-3680
  • Fax: 787-728-8316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number12584
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: