Provider Demographics
NPI:1093229650
Name:FILLERUP, CASEY BOWEN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:BOWEN
Last Name:FILLERUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E CLARK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-5150
Mailing Address - Country:US
Mailing Address - Phone:805-934-0570
Mailing Address - Fax:805-938-7688
Practice Address - Street 1:1145 E CLARK AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5150
Practice Address - Country:US
Practice Address - Phone:805-934-0570
Practice Address - Fax:805-938-7688
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5622213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty