Provider Demographics
NPI:1548350564
Name:CARLO, SIMON ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:ENRIQUE
Last Name:CARLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 CALLE MALAGA
Mailing Address - Street 2:SULTANA
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-1433
Mailing Address - Country:US
Mailing Address - Phone:787-833-7347
Mailing Address - Fax:787-834-9469
Practice Address - Street 1:VALLE HERMOSO SHOPPING CENTER
Practice Address - Street 2:LOC. #8
Practice Address - City:HORMIGUEROS
Practice Address - State:PR
Practice Address - Zip Code:00660
Practice Address - Country:US
Practice Address - Phone:787-834-9469
Practice Address - Fax:787-834-9469
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD08369Medicare UPIN
PR0026365Medicare ID - Type Unspecified