Healthcare Provider Details

I. General information

NPI: 1225533136
Provider Name (Legal Business Name): RAFAEL EDUARDO CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 03/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 HABITAT DR APT 2052
BOULDER CO
80301-3235
US

IV. Provider business mailing address

6200 HABITAT DR APT 2052
BOULDER CO
80301-3235
US

V. Phone/Fax

Practice location:
  • Phone: 720-281-6378
  • Fax:
Mailing address:
  • Phone: 720-281-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number18107
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: