Provider Demographics
NPI:1902995863
Name:CASTILLO, JENNIFER ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR STE L2200
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-930-4020
Mailing Address - Fax:734-769-8948
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR STE L2200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-930-4020
Practice Address - Fax:734-769-8948
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4753520Medicaid
MII35944Medicare UPIN
MI0H17613754Medicare ID - Type Unspecified