Basic Information
| Provider Information | |||||||||
| NPI: | 1700805454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 CORPORATE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 CORPORATE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 40496 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 11995 | 01 | DEAN CARE HMO | OTHER | WI0113 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 391156156 | 01 | TAX ID | OTHER | 30088300 | 05 | WI | MEDICAID | 31662 | 01 | NETWORK HEALTH PLAN | OTHER | 39115615613 | 01 | UNITY HMO | OTHER | 1024501 | 01 | PHYSICIANS PLUS HMO | OTHER | 180034885 | 01 | WI | RAIL ROAD MEDICARE | OTHER |