Provider Demographics
NPI:1063583193
Name:CARRILLO, PETER S (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
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 1:7575 NORTHCLIFF AVE 301
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3265
Mailing Address - Country:US
Mailing Address - Phone:330-425-7806
Mailing Address - Fax:330-405-3026
Practice Address - Street 1:7575 NORTHCLIFF AVE 301
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3265
Practice Address - Country:US
Practice Address - Phone:330-425-7806
Practice Address - Fax:330-405-3026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066260C208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2164321Medicaid
OH0897115Medicare PIN