Provider Demographics
NPI:1225054927
Name:ANNA CARRILLO, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ANNA CARRILLO, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-592-6644
Mailing Address - Street 1:15525 POMERADO RD STE E3
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2427
Mailing Address - Country:US
Mailing Address - Phone:858-592-6644
Mailing Address - Fax:858-592-6393
Practice Address - Street 1:15525 POMERADO RD STE E3
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2427
Practice Address - Country:US
Practice Address - Phone:858-592-6644
Practice Address - Fax:858-592-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62084251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA62084Medicaid
CAWA62084CMedicare ID - Type Unspecified
CAG59790Medicare UPIN