Healthcare Provider Details

I. General information

NPI: 1942373428
Provider Name (Legal Business Name): LAURA DECASTOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

PO BOX 6309
SOUTH BEND IN
46660-6309
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5000
  • Fax: 574-335-0760
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301049652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: