Basic Information
| Provider Information | |||||||||
| NPI: | 1952308322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARBONELL | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SHENANGO AVE | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161461503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243426604 | ||||||||
| FaxNumber: | 7243421601 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 PITT ST | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161462102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243426604 | ||||||||
| FaxNumber: | 7243421601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 36-00-2957 | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | SC004315L | PA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 2104024-000 | 05 | WV | MEDICAID | 2040115 | 05 | OH | MEDICAID | 01773940 | 05 | PA | MEDICAID |