Provider Demographics
NPI:1316971807
Name:CASTRO, J ERIC D (MD)
Entity type:Individual
Prefix:
First Name:J ERIC
Middle Name:D
Last Name:CASTRO
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 1:2260 CHURCHILL CIR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4298
Mailing Address - Country:US
Mailing Address - Phone:773-771-4160
Mailing Address - Fax:
Practice Address - Street 1:1105 W PARK AVE STE 7
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2567
Practice Address - Country:US
Practice Address - Phone:847-773-0369
Practice Address - Fax:847-201-2573
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103419207NS0135X, 2083B0002X, 207P00000X
AZ71511207NS0135X
WI53459-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00264268OtherRAILROAD MEDICARE
IL036103419Medicaid
WI1316971807OtherBLUE CROSS BLUE SHIELD
WI1316971807Medicaid
ILK53332Medicare PIN
WI1316971807Medicaid
ILK14261Medicare PIN