Provider Demographics
NPI:1134165814
Name:CASTRO, JESUS ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ANTONIO
Last Name:CASTRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CALLE COLON
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-2049
Mailing Address - Country:US
Mailing Address - Phone:787-859-1049
Mailing Address - Fax:787-859-1287
Practice Address - Street 1:1 CALLE COLON
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783-0870
Practice Address - Country:US
Practice Address - Phone:787-859-1049
Practice Address - Fax:787-859-1049
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6333208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1134165814OtherNPI
PR1134165814OtherNPI
PR0027724Medicare ID - Type UnspecifiedPROVIDER NUMBER
PRC79690Medicare UPIN