Provider Demographics
NPI:1073617015
Name:CASTRO, WILMA (MD)
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:
Last Name:CASTRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1648
Mailing Address - Country:US
Mailing Address - Phone:606-326-1557
Mailing Address - Fax:606-326-1570
Practice Address - Street 1:617 23RD ST
Practice Address - Street 2:SUITE 12
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2845
Practice Address - Country:US
Practice Address - Phone:606-326-1557
Practice Address - Fax:606-326-1570
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64093578Medicaid
OH2537428Medicaid
KY0953101Medicare ID - Type Unspecified
KYH37604Medicare UPIN