Provider Demographics
NPI:1124048301
Name:CARRILLO, JUAN C (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
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 1:2880 STORY RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127
Mailing Address - Country:US
Mailing Address - Phone:408-929-5439
Mailing Address - Fax:408-929-5010
Practice Address - Street 1:2880 STORY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-3942
Practice Address - Country:US
Practice Address - Phone:408-929-5439
Practice Address - Fax:408-929-5010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G574290OtherMEDICAL PROVIDER #
CA00G574290OtherMEDICAL PROVIDER #