Healthcare Provider Details

I. General information

NPI: 1477040822
Provider Name (Legal Business Name): LAURA ELIZABETH CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 N BLACK CANYON HWY STE 100
PHOENIX AZ
85053
US

IV. Provider business mailing address

15650 N BLACK CANYON HWY STE 100
PHOENIX AZ
85053-4068
US

V. Phone/Fax

Practice location:
  • Phone: 602-866-0550
  • Fax:
Mailing address:
  • Phone: 602-866-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number66746
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: