Provider Demographics
NPI:1396731303
Name:CARRILLO, PEDRO LUCIO JR (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:LUCIO
Last Name:CARRILLO
Suffix:JR
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 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-5114
Mailing Address - Country:US
Mailing Address - Phone:305-541-1606
Mailing Address - Fax:305-649-1129
Practice Address - Street 1:100 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-5114
Practice Address - Country:US
Practice Address - Phone:305-541-1606
Practice Address - Fax:305-649-1129
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL52900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07983Medicare ID - Type Unspecified
FLE31255Medicare UPIN