Provider Demographics
NPI:1205811676
Name:GARRIDO, CUSTODIO A (MD)
Entity type:Individual
Prefix:
First Name:CUSTODIO
Middle Name:A
Last Name:GARRIDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CUSTODIO
Other - Middle Name:A
Other - Last Name:GARRIDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3926 NEW VISION DR
Mailing Address - Street 2:BLDG. H
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2708 GUILFORD ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-9701
Practice Address - Country:US
Practice Address - Phone:260-355-3900
Practice Address - Fax:260-355-3079
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041472A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000175779OtherANTHEM
IN000000570547OtherANTHEM
4556205OtherAETNA
IN100381020Medicaid
IN000000183201OtherANTHEM
00001336580 02OtherUNITED HEALTHCARE
IN2822OtherPHYSICIANS HEALTH PLAN
IN080130069OtherRAILROAD MEDICARE
IN3937240017OtherMEDICARE DMEPOS
IN000000175779OtherANTHEM
4556205OtherAETNA
IN069860ZMedicare PIN
IN069920AMedicare UPIN
IN135920LMedicare PIN