Healthcare Provider Details

I. General information

NPI: 1497098644
Provider Name (Legal Business Name): JASON ROBERT CASTILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 12/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WILLARD
IRVINE CA
92604-4694
US

IV. Provider business mailing address

6 WILLARD
IRVINE CA
92604-4694
US

V. Phone/Fax

Practice location:
  • Phone: 949-262-5780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number61767
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA133196
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA133196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: