1598769119 NPI number — DR. LUIS ENRIQUE CARRILLO MD

Table of content: DR. LUIS ENRIQUE CARRILLO MD (NPI 1598769119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598769119 NPI number — DR. LUIS ENRIQUE CARRILLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARRILLO
Provider First Name:
LUIS
Provider Middle Name:
ENRIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598769119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7097
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33807-7097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-534-8436
Provider Business Mailing Address Fax Number:
863-534-8005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 OSPREY BLVD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
BARTOW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33830-3308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-534-8436
Provider Business Practice Location Address Fax Number:
863-534-8005
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0011X , with the licence number:  ME16832 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 53408Z . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 050395900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53408 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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