MEDICARE: SOFIA MEDINA CARABALLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	3446	PR

General Provider Information

NPI Number	:	1164982971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOFIA MEDINA CARABALLO

Provider Business Mailing Address
First Line	:	1738 CALLE AMARILLO SUMMIT BUILDING
Second Line	:	BOX 16
City	:	SAN JUAN
State	:	PR
Zip	:	00926
Country	:	US
Telephone Number	:	787-472-4567
Fax Number	:

Provider Business Practice Location Address
First Line	:	1738 CALLE AMARILLO SUMMIT BUILDING
Second Line	:	207B
City	:	SAN JUAN
State	:	PR
Zip	:	00926
Country	:	US
Telephone Number	:	718-630-7000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	12/12/2022

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