Provider Demographics
NPI:1326249020
Name:CARILLO, PAUL ERICSON SANTIAGO (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL ERICSON
Middle Name:SANTIAGO
Last Name:CARILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2709
Mailing Address - Country:US
Mailing Address - Phone:732-794-0423
Mailing Address - Fax:
Practice Address - Street 1:9000 FELLOWSHIP RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-3912
Practice Address - Country:US
Practice Address - Phone:908-580-3827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01235100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist