Provider Demographics
NPI:1780877977
Name:CARRILLO, JAIME ORLANDO (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:ORLANDO
Last Name:CARRILLO
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 1:708 DEL PRADO BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5616
Mailing Address - Country:US
Mailing Address - Phone:239-574-5864
Mailing Address - Fax:239-574-1451
Practice Address - Street 1:708 DEL PRADO BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5616
Practice Address - Country:US
Practice Address - Phone:239-574-5864
Practice Address - Fax:239-574-1451
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME105800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDQ952ZOtherMEDICARE PTAN