Basic Information
| Provider Information | |||||||||
| NPI: | 1487764387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276200 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M9912 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 88-136 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00011528 | 05 | NM | MEDICAID | 2067340-01 | 05 | TX | MEDICAID | 8L8793 | 01 | MEDICARE | OTHER |