Provider Demographics
NPI:1043311608
Name:LACARBONARA, FREDRIC EMILIO (MC)
Entity type:Individual
Prefix:
First Name:FREDRIC
Middle Name:EMILIO
Last Name:LACARBONARA
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-0236
Mailing Address - Country:US
Mailing Address - Phone:304-675-4340
Mailing Address - Fax:304-675-1328
Practice Address - Street 1:2520 VALLEY DR
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2031
Practice Address - Country:US
Practice Address - Phone:304-675-4340
Practice Address - Fax:304-675-1328
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15018207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550744227OtherCOMMERICAL INSURANCE
OH0672311Medicaid
WA001721829OtherBCBS
WV0101673000Medicaid
WVLA0790071Medicare PIN