Healthcare Provider Details

I. General information

NPI: 1184252496
Provider Name (Legal Business Name): PERIS R CASTANEDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

PO BOX 24520
NEW YORK NY
10087-3720
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1021050
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036181647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: