Healthcare Provider Details

I. General information

NPI: 1124048301
Provider Name (Legal Business Name): JUAN C CARRILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 STORY RD
SAN JOSE CA
95127-3942
US

IV. Provider business mailing address

2880 STORY RD
SAN JOSE CA
95127
US

V. Phone/Fax

Practice location:
  • Phone: 408-929-5439
  • Fax: 408-929-5010
Mailing address:
  • Phone: 408-929-5439
  • Fax: 408-929-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG57429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: