Provider Demographics
NPI:1316906894
Name:CARRILLO, ALFONSO JULIUS (MD)
Entity type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:JULIUS
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 1:8599 HAVEN AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-919-7288
Practice Address - Street 1:8599 HAVEN AVE.
Practice Address - Street 2:SUITE 300
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4849
Practice Address - Country:US
Practice Address - Phone:909-620-8180
Practice Address - Fax:909-919-7288
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG770832085R0202X, 2085U0001X
OH250000642085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000500781OtherANTHEM
OH2694660Medicaid
OHP00383076OtherRR MEDICARE
CA00G770830Medicaid
OH2694660Medicaid
CA00G770830Medicaid
OHCA4198001Medicare PIN