Basic Information
Provider Information | |||||||||
NPI: | 1841308616 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARCAMO-SANABRIA | ||||||||
FirstName: | ROBERTO | ||||||||
MiddleName: | JOSE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 326 NICHOLS ROAD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | MA | ||||||||
PostalCode: | 01420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788788516 | ||||||||
FaxNumber: | 9788787418 | ||||||||
Practice Location | |||||||||
Address1: | 326 NICHOLS ROAD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | MA | ||||||||
PostalCode: | 01420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788788100 | ||||||||
FaxNumber: | 9788488537 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 08/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 220070 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2060752 | 05 | MA |   | MEDICAID | J27405 | 01 | MA | BCBS MA | OTHER | 468982 | 01 | MA | TUFTS HEALTH PLAN | OTHER |