Provider Demographics
NPI:1609587831
Name:CARRILLO, HECTOR JR (OD)
Entity Type:Individual
Prefix:
First Name:HECTOR
Middle Name:
Last Name:CARRILLO
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2154
Mailing Address - Fax:909-558-2180
Practice Address - Street 1:2195 CLUB CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4170
Practice Address - Country:US
Practice Address - Phone:909-558-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10552OtherTEXAS OPTOMETRY BOARD
CA35503OtherCALIFORNIA OPTOMETRY BOARD