Healthcare Provider Details

I. General information

NPI: 1790265932
Provider Name (Legal Business Name): ANTONIO REYES DEL CASTILLO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 PARCHMAN ROAD 12
PARCHMAN MS
38738-3001
US

IV. Provider business mailing address

1308 S FIFTH AVE
CLEVELAND MS
38732-3609
US

V. Phone/Fax

Practice location:
  • Phone: 662-745-6611
  • Fax:
Mailing address:
  • Phone: 662-545-6414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number966-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: