Provider Demographics
NPI:1659869543
Name:RICO CASTILLO, JESUS OMAR (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:OMAR
Last Name:RICO 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 1:117 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4949
Mailing Address - Country:US
Mailing Address - Phone:215-503-3876
Mailing Address - Fax:
Practice Address - Street 1:117 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4949
Practice Address - Country:US
Practice Address - Phone:215-503-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program