Provider Demographics
NPI:1952556821
Name:RAUL CARRILLO MD PA
Entity Type:Organization
Organization Name:RAUL CARRILLO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-391-1115
Mailing Address - Street 1:929 N. HWY 27/441
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8999
Mailing Address - Country:US
Mailing Address - Phone:352-391-1115
Mailing Address - Fax:352-391-5206
Practice Address - Street 1:929. N. HWY 27/441
Practice Address - Street 2:SUITE 302
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-391-1115
Practice Address - Fax:352-391-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87534207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267028300Medicaid
FLBE 947Medicare PIN