1568654101 NPI number — DR. CARLA ANTOLA LARDIZABAL MD

Table of content: DR. CARLA ANTOLA LARDIZABAL MD (NPI 1568654101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568654101 NPI number — DR. CARLA ANTOLA LARDIZABAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTOLA LARDIZABAL
Provider First Name:
CARLA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568654101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 SE 3RD AVE
Provider Second Line Business Mailing Address:
THIRD FLOOR PBO
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33316-2564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N COMMERCE PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-217-5700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A124251 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD150544 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 4301090806 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME126706 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ME126706 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 161133 . This is a "NBMC GROUP MEDICAID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 4301090806 . This is a "STATE LICENCE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: R0000WFBTV . This is a "NBMC GROUP MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: MD150544 . This is a "OREGON MEDICAL LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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