=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528459856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIA T. POL-CARBALLO, MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2015
-----------------------------------------------------
Last Update Date | 02/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6450 W 21ST CT SUITE #301
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-820-6999
-----------------------------------------------------
Fax | 305-820-9279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6450 W 21ST CT SUITE #301
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-820-6999
-----------------------------------------------------
Fax | 305-820-9279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. MARIA T POL-CARBALLO
-----------------------------------------------------
Credential | M.D,
-----------------------------------------------------
Telephone | 305-820-6999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | ME0060604
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------