Basic Information
| Provider Information | |||||||||
| NPI: | 1619218740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CEBOLLERO | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CEBOLLERO | ||||||||
| OtherFirstName: | CARLOS | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 MICCOSUKEE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504311155 | ||||||||
| FaxNumber: | 8504316975 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MICCOSUKEE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504311155 | ||||||||
| FaxNumber: | 8504316975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2013 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 293845-1 | NY | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 19186 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 140844 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.