Provider Demographics
NPI:1467235515
Name:CARRILLO, JOHN MARION
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARION
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 TIJERAS AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2912
Mailing Address - Country:US
Mailing Address - Phone:505-818-4595
Mailing Address - Fax:
Practice Address - Street 1:6801 JEFFERSON ST NE STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-7390
Practice Address - Country:US
Practice Address - Phone:505-705-1701
Practice Address - Fax:505-212-1253
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program