Provider Demographics
NPI:1083952410
Name:CASTELLANOS CASTILLO, GISSELLE DALILA (MD)
Entity Type:Individual
Prefix:
First Name:GISSELLE
Middle Name:DALILA
Last Name:CASTELLANOS CASTILLO
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-4215
Practice Address - Country:US
Practice Address - Phone:864-522-5300
Practice Address - Fax:864-241-9211
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83147208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC831480Medicaid