Provider Demographics
NPI:1093723215
Name:SANTOS, CARMEN CASTILLO (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:CASTILLO
Last Name:SANTOS
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 1:500 S MAIN ST
Mailing Address - Street 2:1210
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4507
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:714-560-1585
Practice Address - Street 1:15248 11TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3704
Practice Address - Country:US
Practice Address - Phone:760-843-6075
Practice Address - Fax:760-843-6050
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C428620OtherBLUE SHIELD
CA00C428620Medicaid
CA00C428620OtherBLUE SHIELD
CAC42862Medicare ID - Type Unspecified