Provider Demographics
NPI:1841387248
Name:CARRASQUILLO, JOSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:CARRASQUILLO
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:1404 WILLOW LN
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3584
Practice Address - Country:US
Practice Address - Phone:336-903-7845
Practice Address - Fax:336-903-7841
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00302207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02161397Medicaid
PAH43199Medicare UPIN