Basic Information
Provider Information
NPI: 1003801911
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARBALLOSA
FirstName: LEONIDES
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14900 EGAN LN
Address2:  
City: MIAMI LAKES
State: FL
PostalCode: 330142714
CountryCode: US
TelephoneNumber: 3055052780
FaxNumber:  
Practice Location
Address1: 5378 W 16TH AVE
Address2:  
City: HIALEAH
State: FL
PostalCode: 330122165
CountryCode: US
TelephoneNumber: 3058204101
FaxNumber: 3058202885
Other Information
ProviderEnumerationDate: 09/16/2005
LastUpdateDate: 10/07/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate: 03/23/2006
NPIReactivationDate: 03/27/2006
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XME49239FLY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
04565270005FL MEDICAID


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