Provider Demographics
NPI:1386873024
Name:TRINIDAD-CARILLO, IRIS MAE CANETE (MD)
Entity type:Individual
Prefix:
First Name:IRIS MAE
Middle Name:CANETE
Last Name:TRINIDAD-CARILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRIS MAE
Other - Middle Name:CANETE
Other - Last Name:TRINIDAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:INTERSECTION OF RT. 4 & 20 SOUTH
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234-0217
Mailing Address - Country:US
Mailing Address - Phone:304-924-6262
Mailing Address - Fax:304-924-6699
Practice Address - Street 1:INTERSECTION OF RT. 4 & 20 S
Practice Address - Street 2:
Practice Address - City:ROCK CAVE
Practice Address - State:WV
Practice Address - Zip Code:26234-0217
Practice Address - Country:US
Practice Address - Phone:304-924-6262
Practice Address - Fax:304-924-6699
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV24962OtherWV STATE LICENSE