Provider Demographics
NPI:1104111566
Name:ALVAREZ CASILLAS, VICTOR HUGO (SA-C, MD(IMG))
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:HUGO
Last Name:ALVAREZ CASILLAS
Suffix:
Gender:M
Credentials:SA-C, MD(IMG)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1601 MONTE VISTA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6601
Mailing Address - Country:US
Mailing Address - Phone:909-630-7938
Mailing Address - Fax:909-469-2118
Practice Address - Street 1:1601 MONTE VISTA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6601
Practice Address - Country:US
Practice Address - Phone:909-630-7938
Practice Address - Fax:909-469-2118
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11-157246ZC0007X
CAA144136207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104111566Medicaid
FA6452471OtherDEA