Healthcare Provider Details

I. General information

NPI: 1306120746
Provider Name (Legal Business Name): ODALIS CASTELLON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 JOHNSON STREET
HOLLYWOOD FL
33021
US

IV. Provider business mailing address

3449 JOHNSON STREET
HOLLYWOOD FL
33021
US

V. Phone/Fax

Practice location:
  • Phone: 954-964-4113
  • Fax: 954-963-8121
Mailing address:
  • Phone: 954-964-4113
  • Fax: 954-963-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9101779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: