Healthcare Provider Details

I. General information

NPI: 1104917053
Provider Name (Legal Business Name): MANUEL R CASTRESANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST ROOM 2144
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

PO BOX 28068
CHATTANOOGA TN
37424-8068
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3873
  • Fax: 706-721-7763
Mailing address:
  • Phone: 877-899-1033
  • Fax: 423-892-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number022729
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: