Provider Demographics
NPI:1154330504
Name:CARRILLO, PEDRO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 W 1ST ST STE G
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2939
Mailing Address - Country:US
Mailing Address - Phone:714-665-9890
Mailing Address - Fax:
Practice Address - Street 1:9918 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6465
Practice Address - Country:US
Practice Address - Phone:714-644-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93392Medicare UPIN
CA00557500Medicare ID - Type Unspecified