Healthcare Provider Details

I. General information

NPI: 1902009251
Provider Name (Legal Business Name): MARIO EDUARDO CASTELLANOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W THOMAS RD SUITE 680
PHOENIX AZ
85013-4224
US

IV. Provider business mailing address

FILE 56765
LOS ANGELES CA
90074-6765
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6017
  • Fax:
Mailing address:
  • Phone: 602-406-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number42762
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: