Provider Demographics
NPI:1023096211
Name:CASTILLO, ALISSANDRO ROQUE (MD, MBA)
Entity type:Individual
Prefix:
First Name:ALISSANDRO
Middle Name:ROQUE
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602124
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2124
Mailing Address - Country:US
Mailing Address - Phone:704-662-3627
Mailing Address - Fax:704-662-3229
Practice Address - Street 1:478 WILLIAMSON RD
Practice Address - Street 2:SUITE B
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9109
Practice Address - Country:US
Practice Address - Phone:704-662-3627
Practice Address - Fax:704-662-3229
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900793207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912408Medicaid
NC8912408Medicaid
NC2278339AMedicare ID - Type Unspecified