Provider Demographics
NPI:1689667347
Name:CASTILLO DIAZ, FIDEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:FIDEL
Middle Name:E
Last Name:CASTILLO DIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FIDEL
Other - Middle Name:E
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:M-C 717 CSN 440
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:M-C 717 CSN 440
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-7704
Practice Address - Fax:312-413-8283
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124066207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine