Provider Demographics
NPI:1093013799
Name:PEDRO L CARRILLO MD PA
Entity Type:Organization
Organization Name:PEDRO L CARRILLO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:LUCIO
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-824-1117
Mailing Address - Street 1:2140 W 68TH ST
Mailing Address - Street 2:308
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1815
Mailing Address - Country:US
Mailing Address - Phone:305-824-1117
Mailing Address - Fax:305-824-1187
Practice Address - Street 1:2140 W 68TH ST
Practice Address - Street 2:308
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1815
Practice Address - Country:US
Practice Address - Phone:305-824-1117
Practice Address - Fax:305-824-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL52900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty