Healthcare Provider Details

I. General information

NPI: 1194661082
Provider Name (Legal Business Name): SANTIAGO MOCK CASTILLO SR. APRN, RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14606 SW 115TH TER
MIAMI FL
33186-7080
US

IV. Provider business mailing address

14606 SW 115TH TER
MIAMI FL
33186-7080
US

V. Phone/Fax

Practice location:
  • Phone: 786-612-5417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11046879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: