1083692560 NPI number — TIRSO A CASTILLO MD

Table of content: TIRSO A CASTILLO MD (NPI 1083692560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083692560 NPI number — TIRSO A CASTILLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTILLO
Provider First Name:
TIRSO
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1083692560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1528
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31040-1528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-272-1366
Provider Business Mailing Address Fax Number:
478-275-2322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 FAIRVIEW PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-1366
Provider Business Practice Location Address Fax Number:
478-275-2322
Provider Enumeration Date:
01/05/2006

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: 207RG0100X , with the licence number:  048883 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000872066A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52420599-002 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 681242 . This is a "FIRST HEALTH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4653853 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007287 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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