Provider Demographics
NPI:1528312410
Name:MURILLO, MIGUEL ANTONIO (IDC)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANTONIO
Last Name:MURILLO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 BLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2766
Mailing Address - Country:US
Mailing Address - Phone:504-418-9993
Mailing Address - Fax:
Practice Address - Street 1:424 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-2766
Practice Address - Country:US
Practice Address - Phone:504-418-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman