Basic Information
Provider Information | |||||||||
NPI: | 1053416412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARVALLO | ||||||||
FirstName: | ALEJANDRO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 38135 MARKET SQUARE | ||||||||
Address2: |   | ||||||||
City: | ZEPHYRHILLS | ||||||||
State: | FL | ||||||||
PostalCode: | 33542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8135284975 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 36763 EILAND BLVD STE 103 | ||||||||
Address2: |   | ||||||||
City: | ZEPHYRHILLS | ||||||||
State: | FL | ||||||||
PostalCode: | 335420600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139943389 | ||||||||
FaxNumber: | 8133555051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 08/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | ME62950 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 373724100 | 05 | FL |   | MEDICAID | 390007562 | 01 | FL | RR MEDICARE | OTHER | 18832U | 01 | FL | TPA MEDICARE# | OTHER |