Healthcare Provider Details

I. General information

NPI: 1750302386
Provider Name (Legal Business Name): JOSE J CASTELLANOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4941 N KEDZIE AVE
CHICAGO IL
60625-5009
US

IV. Provider business mailing address

PO BOX 577489
CHICAGO IL
60657-7335
US

V. Phone/Fax

Practice location:
  • Phone: 773-509-9099
  • Fax: 773-509-9006
Mailing address:
  • Phone: 872-226-9199
  • Fax: 773-509-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036073558
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036073558
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: