Provider Demographics
NPI:1700107463
Name:CASTILLO, CAROLINE G (MD)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:G
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:ANN
Other - Last Name:GRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-7735
Mailing Address - Fax:503-494-4264
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7735
Practice Address - Fax:503-494-4264
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD191419207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid