Provider Demographics
NPI:1740793090
Name:JUAN C CARRILLO MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JUAN C CARRILLO MD A PROFESSIONAL CORPORATION
Other - Org Name:BUENA SALUD PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-929-5439
Mailing Address - Street 1:2880 STORY RD FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-3942
Mailing Address - Country:US
Mailing Address - Phone:408-929-5439
Mailing Address - Fax:408-929-5010
Practice Address - Street 1:2880 STORY RD FL 2
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-3942
Practice Address - Country:US
Practice Address - Phone:408-929-5439
Practice Address - Fax:408-929-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG574290261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care