Provider Demographics
NPI:1215477633
Name:CASTILLO DE FUENTES, MIGUEL S
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:S
Last Name:CASTILLO DE FUENTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 PARK LN
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33417-5956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 PARK LN
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:FL
Practice Address - Zip Code:33417-5956
Practice Address - Country:US
Practice Address - Phone:305-389-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator