Healthcare Provider Details

I. General information

NPI: 1669421749
Provider Name (Legal Business Name): MITCHELL CASTRO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 SOUTH CHEVY CHASE DRIVE SUITE 102
GLENDALE CA
91205
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-8916
  • Fax: 818-241-7708
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberQ61461
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: