Healthcare Provider Details

I. General information

NPI: 1326231655
Provider Name (Legal Business Name): JERRY REYES CASTRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 S. MARINE CORP DR. - SUITE 104
TAMUNING GU
98913
US

IV. Provider business mailing address

341 S. MARINE CORP DRIVE - SUITE 104
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-989-1368
  • Fax: 671-989-2360
Mailing address:
  • Phone: 671-989-1368
  • Fax: 971-989-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number236169
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberM-1744
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: