Provider Demographics
NPI:1215585096
Name:DECARRILLO, DAMON L (STUDENT)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:L
Last Name:DECARRILLO
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WESLEYAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-1536
Mailing Address - Country:US
Mailing Address - Phone:917-696-7438
Mailing Address - Fax:
Practice Address - Street 1:1201 WESLEYAN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-1536
Practice Address - Country:US
Practice Address - Phone:917-696-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program