Provider Demographics
NPI:1790291086
Name:CASTRILLON, JEFFREY WILLIAM
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:CASTRILLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15107 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-782-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA20A19504207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790291086OtherKAISER
CA1790291086Medicaid