Basic Information
| Provider Information | |||||||||
| NPI: | 1124469101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | LUCAS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 2436 S ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809162408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193912336 | ||||||||
| FaxNumber: | 7193911625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00202128 | CO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 55975364 | 05 | CO | MEDICAID | DEN.00202128 | 01 | CO | CO OPTOMETRY LICENSE | OTHER |