Healthcare Provider Details

I. General information

NPI: 1689667347
Provider Name (Legal Business Name): FIDEL E CASTILLO DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: FIDEL E CASTILLO MD

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST M-C 717 CSN 440
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

840 S WOOD ST M-C 717 CSN 440
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7704
  • Fax: 312-413-8283
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036124066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: