Provider Demographics
NPI:1902022387
Name:CASTILLO, VICTOR IVAN
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:IVAN
Last Name:CASTILLO
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 1:15613 SW 62ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2573
Mailing Address - Country:US
Mailing Address - Phone:305-387-5737
Mailing Address - Fax:305-260-9177
Practice Address - Street 1:15613 SW 62ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2573
Practice Address - Country:US
Practice Address - Phone:305-387-5737
Practice Address - Fax:305-260-9177
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40473225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist