Provider Demographics
NPI:1891187027
Name:LUIS E CARRILLO MD
Entity Type:Organization
Organization Name:LUIS E CARRILLO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-534-8436
Mailing Address - Street 1:PO BOX 7097
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-7097
Mailing Address - Country:US
Mailing Address - Phone:863-534-8436
Mailing Address - Fax:863-534-8005
Practice Address - Street 1:2200 OSPREY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3308
Practice Address - Country:US
Practice Address - Phone:863-534-8436
Practice Address - Fax:863-534-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME168322083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty