Provider Demographics
NPI:1467425421
Name:RILLERA, CARMELO V (MD)
Entity Type:Individual
Prefix:
First Name:CARMELO
Middle Name:V
Last Name:RILLERA
Suffix:
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 1:2200 PASEO VERDE PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2703
Mailing Address - Country:US
Mailing Address - Phone:702-616-5801
Mailing Address - Fax:
Practice Address - Street 1:8205 W WARM SPRINGS RD STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3646
Practice Address - Country:US
Practice Address - Phone:702-616-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1467425421Medicaid
NVEP270XMedicare PIN
NVEP270YMedicare PIN