Provider Demographics
NPI:1114453511
Name:CARRILLO, SHANE CARLOS (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:CARLOS
Last Name:CARRILLO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S. 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219
Mailing Address - Country:US
Mailing Address - Phone:804-828-7912
Mailing Address - Fax:
Practice Address - Street 1:107 S. 5TH ST.
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219
Practice Address - Country:US
Practice Address - Phone:804-828-7912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012653482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry