Basic Information
Provider Information | |||||||||
NPI: | 1972178739 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTILLO MUNOZ | ||||||||
FirstName: | KENIA | ||||||||
MiddleName: | JAZMIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GONZALEZ MUNOZ | ||||||||
OtherFirstName: | KENIA | ||||||||
OtherMiddleName: | JAZMIN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 13801 WESTBORO DR | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951273135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4086911189 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1171 HOMESTEAD RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | SANTA CLARA | ||||||||
State: | CA | ||||||||
PostalCode: | 950505485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4083202590 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2021 | ||||||||
LastUpdateDate: | 05/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.