MEDICARE: DR. CARLOS ERMOCILLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	11167	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497799407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS ERMOCILLA M.D.

Provider Business Mailing Address
First Line	:	3121 S MARYLAND PKWY STE 204
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2302
Country	:	US
Telephone Number	:	702-320-3627
Fax Number	:	702-216-3822

Provider Business Practice Location Address
First Line	:	150 E HARMON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-4533
Country	:	US
Telephone Number	:	702-796-1116
Fax Number	:	702-692-4740

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	11/10/2017

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