Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1100X | Ophthalmic |
NPI | 1225524424 |
---|---|
Provider Name | Cristobal Andres Yacelga Castillo |
First Address | Portland, OR 97201-3479 |
Second Address | Portland, OR 97239-2964 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2018 |
Last Update Date | 11/07/2018 |