Provider Demographics
NPI:1417951211
Name:CASTILLO, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:433 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1690
Practice Address - Country:US
Practice Address - Phone:419-630-2028
Practice Address - Fax:419-630-2029
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.132814207RC0000X, 207RI0011X
MI4301053638207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0326581Medicaid
MI4754590Medicaid
MI4754590Medicaid