Provider Demographics
NPI:1861436339
Name:CARRILLO, MARTIN ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ANTONIO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70304
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91117-7304
Mailing Address - Country:US
Mailing Address - Phone:626-792-9016
Mailing Address - Fax:
Practice Address - Street 1:5451 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2609
Practice Address - Country:US
Practice Address - Phone:909-464-8666
Practice Address - Fax:909-464-8913
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78590207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G785900Medicaid
CA00G785901Medicare PIN
CA00G785900Medicaid
CAWG78590BMedicare PIN