Provider Demographics
NPI:1306893573
Name:CASTILLO, PROBO H (MD)
Entity type:Individual
Prefix:
First Name:PROBO
Middle Name:H
Last Name:CASTILLO
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:PO BOX 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 W 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3894
Practice Address - Country:US
Practice Address - Phone:423-586-4234
Practice Address - Fax:865-985-7077
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31733207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3854448Medicaid
KY64045370Medicaid
TN4069306OtherBC BS
VA005359U26Medicare PIN
TN4069306OtherBC BS
TN3854448Medicare PIN
KY64045370Medicaid