Provider Demographics
NPI:1790707065
Name:CASILLAS, JACQUELINE NIETO (MD, MSHS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:NIETO
Last Name:CASILLAS
Suffix:
Gender:F
Credentials:MD, MSHS
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Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:A2-410 MDCC
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-206-3952
Mailing Address - Fax:310-206-0209
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:A2-410 MDCC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-206-3952
Practice Address - Fax:310-206-0209
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA628612080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053510Medicaid
CA00A628610Medicaid
CAW11810Medicare ID - Type UnspecifiedGROUP MEDICARE
CAWA62861AMedicare ID - Type Unspecified
CAGR0053510Medicaid