Provider Demographics
NPI:1790888626
Name:CASTRO, IDA RAQUEL (OD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:RAQUEL
Last Name:CASTRO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CALLE SANTIAGO VIDARTE
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-3303
Mailing Address - Country:US
Mailing Address - Phone:787-638-4165
Mailing Address - Fax:787-893-0643
Practice Address - Street 1:21 CALLE SANTIAGO VIDARTE
Practice Address - Street 2:
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767-3312
Practice Address - Country:US
Practice Address - Phone:787-893-0643
Practice Address - Fax:787-893-0643
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist