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General NPI Number Information
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NPI Number | 1093883340
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Entity Type | Individual
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Provider Name | IMELDA CASTILLO TAN O.D.
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Gender | Female
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Dates
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Enumeration Date | 12/02/2006
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Last Update Date | 07/24/2013
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Provider Practice Location Address
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Address Line | 3166 KENSINGTON AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19134-2421
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Country | US
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Telephone | 215-425-3937
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Fax | 215-739-3661
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Provider Business Mailing Address
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Address Line | 7901 ROCKWELL AVENUE
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City | PHILADELPHIA
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State | PA
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Zip | 19111-2222
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Country | US
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Telephone | 215-342-0392
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Fax | 215-739-3661
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG000945
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License Number State | PA
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