Provider Demographics
NPI:1316155443
Name:CASTILLO-SALAZAR, IVAN G (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:G
Last Name:CASTILLO-SALAZAR
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 1:7030 NEW SANGER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-4073
Mailing Address - Country:US
Mailing Address - Phone:254-753-7007
Mailing Address - Fax:254-753-5225
Practice Address - Street 1:7030 NEW SANGER RD STE 102
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4073
Practice Address - Country:US
Practice Address - Phone:254-753-7007
Practice Address - Fax:254-753-5225
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7090207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFH213ZMedicare PIN