Healthcare Provider Details

I. General information

NPI: 1588007249
Provider Name (Legal Business Name): MARTIN DANIEL CASTILLO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD 3RD FL
LAKE CHARLES LA
70601-8991
US

IV. Provider business mailing address

PO BOX 122108 DEPT 2108
DALLAS TX
75312-2108
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-8100
  • Fax: 337-475-8510
Mailing address:
  • Phone: 337-494-2919
  • Fax: 337-494-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07248
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: