Basic Information
| Provider Information | |||||||||
| NPI: | 1649472010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FILLMORE | ||||||||
| FirstName: | CAPRI | ||||||||
| MiddleName: | MARA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 464 S SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546121401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083233341 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 464 S SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546121401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083233341 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43268 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005273601 | 01 | MEDICARE PART B | OTHER | 8HM164 | 01 | NM | PROVIDER NUMBER FOR MEDICARE | OTHER | 91934770 | 05 | NM | MEDICAID | H3451 | 05 | NM | MEDICAID | HSZ196 | 01 | NM | MEDICARE PART B | OTHER | K3526 | 05 | NM | MEDICAID |