NPIMap

Individual provider Active NPI

Bernardo Jose Carrillo, P.A.

  • Medical Physician Assistant
  • Huntington Park, CA
National Provider Identifier
1063518611
Registry record updated Nov 6, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
PA14716 Issued in CA
Practice address
2975 Zoe Ave
Huntington Park, CA 90255
Phone
(322) 826-9449
Fax
(323) 582-8500
NPI assigned
Sep 14, 2006
Last updated
Nov 6, 2017By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X PA14716 CA Primary

Addresses

Primary practice location

2975 Zoe Ave
Huntington Park, CA 90255

Mailing address

PO Box 2203
Downey, CA 90242-0203
Phone (562) 923-2502

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080418000504 CA Practitioner - Physician Assistant 5890873699 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
14716CAMDOptometrist

Practice roles

OrganizationSpecialtyStatusNew patients
Northeast Community Clinic CurrentSince Jan 25, 2008 Accepting new patients
Northeast Community Clinic CurrentSince Jan 25, 2008 Accepting new patients

Locations

2550 W Main St
Ste 301
Alhambra, CA 91801
Phone (626) 457-6900

4129 Gage Ave
Bell Gardens, CA 90201
Phone (323) 589-0916

2975 Zoe Ave
Huntington Park, CA 90255
Phone (323) 771-8400

1414 S Grand Ave
Ste 380
Los Angeles, CA 90015
Phone (213) 222-1300

Ownership & related parties

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Northeast Community ClinicWilmington, CA, CCN 551052 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020
Huntington Park Community Health CenterHuntington Park, CA, CCN 551179 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020
Diabetes & Endocrinology Specialty CenterLos Angeles, CA, CCN 921031 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020
Northeast Community ClinicLos Angeles, CA, CCN 921033 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020
Northeast Community ClinicHarbor City, CA, CCN 921034 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020
Northeast Community ClinicBell, CA, CCN 921035 Federally qualified health center Corporate Officer
W-2 Managing Employee		 Jun 1, 2020
Jun 1, 2020

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158192000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1509926400000",
    "number": "1063518611",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2203",
            "city": "DOWNEY",
            "state": "CA",
            "postal_code": "902420203",
            "telephone_number": "562-923-2502"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2975 ZOE AVE",
            "city": "HUNTINGTON PARK",
            "state": "CA",
            "postal_code": "90255",
            "telephone_number": "322-826-9449",
            "fax_number": "323-582-8500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CARRILLO",
        "first_name": "BERNARDO",
        "middle_name": "JOSE",
        "name_prefix": "Mr.",
        "credential": "P.A.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-14",
        "last_updated": "2017-11-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "CA",
            "license": "PA14716",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Huntington Park, CA

Sources for this page

Verify at the official NPI Registry.