Healthcare Provider Details

I. General information

NPI: 1275847360
Provider Name (Legal Business Name): JEREMIAH DANE FILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 MCKENZIE AVE
ARNOLD CA
95223-9694
US

IV. Provider business mailing address

2855 MCKENZIE AVENUE PMB 803
ARNOLD CA
95223
US

V. Phone/Fax

Practice location:
  • Phone: 209-653-2135
  • Fax: 209-259-1654
Mailing address:
  • Phone: 209-653-2135
  • Fax: 209-259-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA117793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: