Healthcare Provider Details

I. General information

NPI: 1417560772
Provider Name (Legal Business Name): LIZZET CASTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 ATRISCO DR NW
ALBUQUERQUE NM
87120-1627
US

IV. Provider business mailing address

223 SOLANO DR NE APT B
ALBUQUERQUE NM
87108-1052
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-7500
  • Fax:
Mailing address:
  • Phone: 505-712-2875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2025-0492
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: