1386875896 NPI number — MARIO CARCAMO PA

Table of content: (NPI 1386875896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386875896 NPI number — MARIO CARCAMO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIO CARCAMO PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARIO CARCAMO O.D.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386875896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7795 W FLAGLER ST
Provider Second Line Business Mailing Address:
#63
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33144-2359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-662-2990
Provider Business Mailing Address Fax Number:
305-380-7106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7795 W FLAGLER ST
Provider Second Line Business Practice Location Address:
#63
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33144-2368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-662-2990
Provider Business Practice Location Address Fax Number:
305-380-7106
Provider Enumeration Date:
07/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CARCAMO
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
IVAN
Authorized Official Title or Position:
MANAGER OWNER
Authorized Official Telephone Number:
305-662-2990

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 078938100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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