Healthcare Provider Details

I. General information

NPI: 1538422316
Provider Name (Legal Business Name): PABLO R CASTRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W KETTLEMAN LN SUITE 200
LODI CA
95242-4337
US

IV. Provider business mailing address

PO BOX 241011
LODI CA
95241-9511
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-8540
  • Fax: 209-368-2885
Mailing address:
  • Phone: 209-339-7435
  • Fax: 209-333-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12389
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: