Healthcare Provider Details

I. General information

NPI: 1871985416
Provider Name (Legal Business Name): SAMUEL DOLAN CASTILLO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 W EL CAMINO REAL
MOUNTAIN VIEW CA
94040-2610
US

IV. Provider business mailing address

887 SALT LAKE DR
SAN JOSE CA
95133-2922
US

V. Phone/Fax

Practice location:
  • Phone: 650-961-7370
  • Fax: 650-961-2360
Mailing address:
  • Phone: 408-667-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: