Provider Demographics
NPI:1841306982
Name:CASTILLO, JUVENAL LIPANA (MD)
Entity type:Individual
Prefix:DR
First Name:JUVENAL
Middle Name:LIPANA
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 1:6172 CHABLIS LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-9005
Mailing Address - Country:US
Mailing Address - Phone:917-816-4427
Mailing Address - Fax:269-321-0156
Practice Address - Street 1:6172 CHABLIS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-9005
Practice Address - Country:US
Practice Address - Phone:917-816-4427
Practice Address - Fax:269-321-0156
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087182208100000X
IL036116406208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
I59129Medicare UPIN
K29956Medicare ID - Type Unspecified