Provider Demographics
NPI:1609389758
Name:MENJIVAR CASTILLO, LUIS JAYSON
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:JAYSON
Last Name:MENJIVAR CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7265 MONTEREY ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-6921
Mailing Address - Country:US
Mailing Address - Phone:408-657-3431
Mailing Address - Fax:
Practice Address - Street 1:7265 MONTEREY ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-6921
Practice Address - Country:US
Practice Address - Phone:408-657-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service