Provider Demographics
NPI:1497799407
Name:ERMOCILLA, CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:ERMOCILLA
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 1:3121 S MARYLAND PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2302
Mailing Address - Country:US
Mailing Address - Phone:702-320-3627
Mailing Address - Fax:702-216-3822
Practice Address - Street 1:150 E HARMON AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-4533
Practice Address - Country:US
Practice Address - Phone:702-796-1116
Practice Address - Fax:702-692-4740
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505702Medicaid
I27681Medicare UPIN
100531Medicare ID - Type Unspecified