Provider Demographics
NPI:1649472010
Name:FILLMORE, CAPRI MARA (MD)
Entity type:Individual
Prefix:DR
First Name:CAPRI
Middle Name:MARA
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 S SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:WI
Mailing Address - Zip Code:54612-1401
Mailing Address - Country:US
Mailing Address - Phone:608-323-3341
Mailing Address - Fax:
Practice Address - Street 1:464 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1401
Practice Address - Country:US
Practice Address - Phone:608-323-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
005273601OtherMEDICARE PART B
NM8HM164OtherPROVIDER NUMBER FOR MEDICARE
NM91934770Medicaid
NMH3451Medicaid
NMHSZ196OtherMEDICARE PART B
NMK3526Medicaid
NM320057Medicare Oscar/Certification
NMH3451Medicaid
NMK3526Medicaid