Provider Demographics
NPI:1477271096
Name:CASTILLO, JOSUE ADAN (IDC)
Entity type:Individual
Prefix:
First Name:JOSUE
Middle Name:ADAN
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 KEARNY VILLA RD APT 141
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1975
Mailing Address - Country:US
Mailing Address - Phone:786-691-0293
Mailing Address - Fax:
Practice Address - Street 1:BLDG 14, 34101 FARENHOLD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92132-0001
Practice Address - Country:US
Practice Address - Phone:789-691-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program