Provider Demographics
NPI:1932533601
Name:CARRASQUILLO, ERNESTO III (IDC)
Entity Type:Individual
Prefix:MR
First Name:ERNESTO
Middle Name:
Last Name:CARRASQUILLO
Suffix:III
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 CRESTMONT PLACE
Mailing Address - Street 2:APT 302
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-651-7360
Mailing Address - Fax:
Practice Address - Street 1:1804 CRESTMONT PLACE
Practice Address - Street 2:APT 302
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-651-7360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman