Provider Demographics
NPI:1336214469
Name:CARILLO, DOMINICK J (MD)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:J
Last Name:CARILLO
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 1:100 PARK ST
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5100
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:GLENS FALLS HOSPITAL
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-3000
Practice Address - Fax:518-926-3127
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189110207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
70021AOtherMEDICARE PART B
70021AOtherMEDICARE PART B
G70133Medicare PIN