Provider Demographics
NPI:1215307590
Name:CARONONGAN, CARMELITO MIRALLES (MD)
Entity type:Individual
Prefix:MR
First Name:CARMELITO
Middle Name:MIRALLES
Last Name:CARONONGAN
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 1:120 S. 11TH ST.
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-988-8154
Mailing Address - Fax:
Practice Address - Street 1:120 S. 11TH ST.
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-988-8154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.060412208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics