Provider Demographics
NPI:1992734479
Name:CASTILLO, MICHAEL GEORGE (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 MEDICAL DR
Mailing Address - Street 2:6300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5640
Mailing Address - Country:US
Mailing Address - Phone:210-614-8400
Mailing Address - Fax:210-614-8165
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:6300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-614-8400
Practice Address - Fax:210-614-8165
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24459103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100467303Medicaid
TXR64731Medicare UPIN
TX100467303Medicaid