Provider Demographics
NPI:1093247934
Name:CASILLAS, CARLOS ANTHONY
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTHONY
Last Name:CASILLAS
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 1:234 GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2364
Mailing Address - Country:US
Mailing Address - Phone:513-584-7425
Mailing Address - Fax:513-584-7681
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8000
Practice Address - Fax:513-584-0468
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.142290207R00000X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics