Provider Demographics
NPI:1861905739
Name:JACASTILLANO PLLC
Entity type:Organization
Organization Name:JACASTILLANO PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTILLANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-252-3930
Mailing Address - Street 1:54626 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-6001
Mailing Address - Country:US
Mailing Address - Phone:904-252-3930
Mailing Address - Fax:
Practice Address - Street 1:5310 BREEZE HILL PL
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2725
Practice Address - Country:US
Practice Address - Phone:904-252-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011004552085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301100455OtherMI LIC#