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General NPI Number Information
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NPI Number | 1205811676
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Entity Type | Individual
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Provider Name | CUSTODIO A. GARRIDO M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/08/2005
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Last Update Date | 03/24/2016
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Provider Practice Location Address
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Address Line | 2708 GUILFORD ST
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City | HUNTINGTON
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State | IN
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Zip | 46750-9701
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Country | US
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Telephone | 260-355-3900
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Fax | 260-355-3079
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Provider Business Mailing Address
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Address Line | 3926 NEW VISION DR BLDG. H
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City | FORT WAYNE
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State | IN
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Zip | 46845-1712
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Country | US
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Telephone | 260-373-9700
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Fax | 260-373-9740
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01041472A
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License Number State | IN
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