Healthcare Provider Details

I. General information

NPI: 1528349933
Provider Name (Legal Business Name): UPPER WEST SIDE MEDICAL P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W 79TH ST
NEW YORK NY
10024-6454
US

IV. Provider business mailing address

PO BOX 3234 CHURCH STREET STATION
NEW YORK NY
10008-3234
US

V. Phone/Fax

Practice location:
  • Phone: 212-785-1059
  • Fax: 212-269-2901
Mailing address:
  • Phone: 212-785-1059
  • Fax: 212-269-2901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number232065-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number257247
License Number StateNY

VIII. Authorized Official

Name: DR. RAPHAEL A CASTILLO
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 646-267-2300