Provider Demographics
NPI:1053491936
Name:CARRILLO, MARIO (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1676 SUNSET AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-624-4690
Practice Address - Fax:315-624-4840
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-03-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY2135402086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01976636Medicaid
NYJ400250598Medicare PIN
NY01976636Medicaid