Provider Demographics
NPI:1740248038
Name:REGILLO, CARL D (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:REGILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 BUTLER PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1560
Mailing Address - Country:US
Mailing Address - Phone:800-331-6634
Mailing Address - Fax:267-420-1360
Practice Address - Street 1:4060 BUTLER PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1560
Practice Address - Country:US
Practice Address - Phone:800-331-6634
Practice Address - Fax:267-420-1360
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06700400207W00000X, 207WX0107X
PAMD042354L207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA704829EV6Medicare PIN
NJ004761AHDMedicare PIN
NJ004761AHDMedicare PIN
NJ5272106Medicaid
MD4127676Medicaid
NJ527106Medicaid
PA231932869OtherPA TIN
NJ004761Medicare ID - Type UnspecifiedNJ MEDICARE
MD4127676Medicaid
NJ527106Medicaid