Basic Information
| Provider Information | |||||||||
| NPI: | 1861436339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70304 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911177304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267929016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5451 WALNUT AVE | ||||||||
| Address2: | |||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917102609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094648666 | ||||||||
| FaxNumber: | 9094648913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G78590 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G785900 | 05 | CA | MEDICAID |