1316971807 NPI number — J ERIC D CASTRO MD

Table of content: J ERIC D CASTRO MD (NPI 1316971807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316971807 NPI number — J ERIC D CASTRO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTRO
Provider First Name:
J ERIC
Provider Middle Name:
D
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:
1316971807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2260 CHURCHILL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-4298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-771-4160
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 W PARK AVE STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-773-0369
Provider Business Practice Location Address Fax Number:
847-201-2573
Provider Enumeration Date:
07/10/2006

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: 207NS0135X , with the licence number:  036103419 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 71511 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 53459-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083B0002X , with the licence number: 036103419 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 036103419 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00264268 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036103419 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1316971807 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1316971807 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".