Basic Information
| Provider Information | |||||||||
| NPI: | 1902420045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | ALVARO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | CALLE EL MAIZAL RESIDENCIAL POLO SUR CASA 112-SANTIAG | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | LIMA | ||||||||
| PostalCode: | 15023 | ||||||||
| CountryCode: | PE | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 NW 12 AVENUE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055856042 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2020 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/18/2022 | ||||||||
| NPIReactivationDate: | 01/27/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.