Provider Demographics
NPI:1750302386
Name:CASTELLANOS, JOSE J (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:J
Last Name:CASTELLANOS
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:PO BOX 577489
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7335
Mailing Address - Country:US
Mailing Address - Phone:872-226-9199
Mailing Address - Fax:773-509-9006
Practice Address - Street 1:4941 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5009
Practice Address - Country:US
Practice Address - Phone:773-509-9099
Practice Address - Fax:773-509-9006
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073558173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01616720OtherBCBS
IL036073558Medicaid
ILD16505Medicare UPIN
IL036073558Medicaid