MEDICARE: JEANNA MAE CASTRO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	472887029	CA

General Provider Information

NPI Number	:	1790134542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNA MAE CASTRO

Provider Business Mailing Address
First Line	:	3609 4TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4105
Country	:	US
Telephone Number	:	619-255-0789
Fax Number	:

Provider Business Practice Location Address
First Line	:	3609 4TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4105
Country	:	US
Telephone Number	:	619-255-0789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	06/11/2016

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Directions to “ JEANNA MAE CASTRO ” Practice Location

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