Healthcare Provider Details

I. General information

NPI: 1356654529
Provider Name (Legal Business Name): JOSE ADENAUER CASTIBLANCO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 CONNECTICUT BLVD
EAST HARTFORD CT
06108-3013
US

IV. Provider business mailing address

PO BOX 269
HARRISON NY
10528-0269
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-1359
  • Fax: 860-528-5180
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000930
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00320800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006624
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: