Provider Demographics
NPI:1205827201
Name:CARRILLO-NUNEZ, IGNACIO MARCOS (MD)
Entity Type:Individual
Prefix:
First Name:IGNACIO
Middle Name:MARCOS
Last Name:CARRILLO-NUNEZ
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 1:18111 BROOKHURST ST
Mailing Address - Street 2:6200
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-378-5516
Mailing Address - Fax:714-378-5517
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:STE 719
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3412
Practice Address - Country:US
Practice Address - Phone:562-591-1324
Practice Address - Fax:562-437-1054
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA510492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACK323ZOtherMEDICARE PTAN
CA00A0510490Medicaid
CA00A0510490Medicaid