Provider Demographics
NPI:1982775672
Name:CASTILLEJOS EYE INSTITUTE MEDICAL GROUP
Entity type:Organization
Organization Name:CASTILLEJOS EYE INSTITUTE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CASTILLEJOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-422-1471
Mailing Address - Street 1:342 F ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2625
Mailing Address - Country:US
Mailing Address - Phone:619-422-1471
Mailing Address - Fax:619-422-0450
Practice Address - Street 1:342 F ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-422-1471
Practice Address - Fax:619-422-0450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASTILLEJOS EYE INSTITUTE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37652207W00000X
207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080800Medicaid
CAGSD004480Medicaid
CAW14161Medicare PIN