Provider Demographics
NPI:1568482628
Name:CASTILLO, JOSE A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:A
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5372 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2165
Mailing Address - Country:US
Mailing Address - Phone:786-478-3554
Mailing Address - Fax:
Practice Address - Street 1:5372 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2165
Practice Address - Country:US
Practice Address - Phone:786-478-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2849152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620096600Medicaid
FL20589Medicare PIN
FLU57674Medicare UPIN