Provider Demographics
NPI:1609857200
Name:CASTILLO, MARLON FIDEL (MD)
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:FIDEL
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC, ATTN CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine