Healthcare Provider Details

I. General information

NPI: 1205363967
Provider Name (Legal Business Name): MARTHA CASTILLO R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13750 JAMAICA AVE
JAMAICA NY
11435-3610
US

IV. Provider business mailing address

13802 QUEENS BLVD
BRIARWOOD NY
11435-2642
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-5100
  • Fax:
Mailing address:
  • Phone: 718-657-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number527143
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: