Provider Demographics
NPI:1215258256
Name:CARRILLO-MASSA, MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:CARRILLO-MASSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:CARRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:401 MAPLEWOOD DR STE 6
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5848
Mailing Address - Country:US
Mailing Address - Phone:561-744-2724
Mailing Address - Fax:561-743-7781
Practice Address - Street 1:401 MAPLEWOOD DR STE 6
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-744-2724
Practice Address - Fax:561-743-7781
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIO427AMedicare PIN
FL009028700Medicaid