Healthcare Provider Details

I. General information

NPI: 1568454932
Provider Name (Legal Business Name): MARIO L. CASTILLO MALDONADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO SUSUA BAJA CARR 127 SECTOR 4 CALLES
YAUCO PR
00698
US

IV. Provider business mailing address

229 CALLE PROL 25 DE JULIO STE #1
YAUCO PR
00698
US

V. Phone/Fax

Practice location:
  • Phone: 787-267-0302
  • Fax: 787-267-0302
Mailing address:
  • Phone: 787-267-0302
  • Fax: 787-267-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10065
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: