1366610396 NPI number — DR. JOE MANUEL CASILLAS JR. MD

Table of content: DR. JOE MANUEL CASILLAS JR. MD (NPI 1366610396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366610396 NPI number — DR. JOE MANUEL CASILLAS JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASILLAS
Provider First Name:
JOE
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1366610396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11234 ANDERSON ST
Provider Second Line Business Mailing Address:
HOUSE STAFF OFFICE CP 21005
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-8131
Provider Business Mailing Address Fax Number:
909-558-0430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11234 ANDERSON ST
Provider Second Line Business Practice Location Address:
HOUSE STAFF OFFICE CP 21005
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-558-8131
Provider Business Practice Location Address Fax Number:
909-558-0430
Provider Enumeration Date:
02/12/2008

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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