Provider Demographics
NPI:1609587831
Name:CARRILLO, HECTOR JR (OD)
Entity type:Individual
Prefix:
First Name:HECTOR
Middle Name:
Last Name:CARRILLO
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15021 ELMBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-4702
Mailing Address - Country:US
Mailing Address - Phone:562-305-7539
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4215
Practice Address - Country:US
Practice Address - Phone:714-509-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35503OtherCALIFORNIA OPTOMETRY BOARD
CA35503OtherCALIFORNIA OPTOMETRY BOARD