Provider Demographics
NPI:1275847360
Name:FILLO, JEREMIAH DANE (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DANE
Last Name:FILLO
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 1:2412 3RD ST
Mailing Address - Street 2:PO BOX 249
Mailing Address - City:HUGHSON
Mailing Address - State:CA
Mailing Address - Zip Code:95326-9310
Mailing Address - Country:US
Mailing Address - Phone:209-558-7250
Mailing Address - Fax:209-558-6033
Practice Address - Street 1:2412 3RD ST
Practice Address - Street 2:
Practice Address - City:HUGHSON
Practice Address - State:CA
Practice Address - Zip Code:95326-9310
Practice Address - Country:US
Practice Address - Phone:209-558-7250
Practice Address - Fax:209-558-6033
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA117793207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program