Basic Information
| Provider Information | |||||||||
| NPI: | 1235685322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACHADO COLON | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 475 S JOHN RODES BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212411170 | ||||||||
| FaxNumber: | 3212411171 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 S JOHN RODES BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212411170 | ||||||||
| FaxNumber: | 3212411171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2016 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 17-32967 | FL | N | 106E00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 019248800 | 05 | FL | MEDICAID |