Provider Demographics
NPI:1790732105
Name:CASTILLO, VIVIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:CASTILLO-BARONIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2055 W HOSPITAL DR
Mailing Address - Street 2:STE 195
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7892
Mailing Address - Country:US
Mailing Address - Phone:520-297-1595
Mailing Address - Fax:520-572-2301
Practice Address - Street 1:2055 W HOSPITAL DR
Practice Address - Street 2:STE 195
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7892
Practice Address - Country:US
Practice Address - Phone:520-297-1595
Practice Address - Fax:520-572-2301
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ34689OtherSTATE LICENSE
AZ089359Medicaid
AZ34689OtherSTATE LICENSE
AZ089359Medicaid