Provider Demographics
NPI:1023423548
Name:CASTILLO, JENNIFER SODANET (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SODANET
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SODANET
Other - Last Name:KHEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2156 MONTEBELLO TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2170
Mailing Address - Country:US
Mailing Address - Phone:310-546-5568
Mailing Address - Fax:
Practice Address - Street 1:2156 MONTEBELLO TOWN CTR
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2170
Practice Address - Country:US
Practice Address - Phone:310-546-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15317152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist