Provider Demographics
NPI:1376633586
Name:CARRILLO, RODOLFO BARTOLOME SR (MD)
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:BARTOLOME
Last Name:CARRILLO
Suffix:SR
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 1:420 BROAD ST SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-536-8885
Mailing Address - Fax:770-536-8725
Practice Address - Street 1:420 BROAD ST SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3726
Practice Address - Country:US
Practice Address - Phone:770-536-8885
Practice Address - Fax:770-536-8725
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033243208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0TH000Medicaid
GAG14961Medicare ID - Type Unspecified