Provider Demographics
NPI:1972624856
Name:ASTILLA, MICHAEL (MS,CO,BOCP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ASTILLA
Suffix:
Gender:M
Credentials:MS,CO,BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 CRUTCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2725
Mailing Address - Country:US
Mailing Address - Phone:919-471-4994
Mailing Address - Fax:919-471-4995
Practice Address - Street 1:314 CRUTCHFIELD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2725
Practice Address - Country:US
Practice Address - Phone:919-471-4994
Practice Address - Fax:919-471-4995
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795027Medicaid
4215300001Medicare NSC