Provider Demographics
NPI:1215901855
Name:TAN, CARLOS CASTILO (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:CASTILO
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-4135
Mailing Address - Country:US
Mailing Address - Phone:770-503-0221
Mailing Address - Fax:770-503-0023
Practice Address - Street 1:3 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4135
Practice Address - Country:US
Practice Address - Phone:770-503-0221
Practice Address - Fax:770-503-0023
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27927208D00000X
GA027927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000304719HMedicaid
GA000304719HMedicaid
GA02BDCMTOtherMEDICARE NUMBER
WI34596700Medicaid