Healthcare Provider Details

I. General information

NPI: 1881647170
Provider Name (Legal Business Name): EDNA C DECASTRO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 11TH ST STE 14
CHILLICOTHEE MO
64601-1676
US

IV. Provider business mailing address

13528 LIV 230
CHILLICOTHEE MO
64601-6398
US

V. Phone/Fax

Practice location:
  • Phone: 660-646-2682
  • Fax: 660-646-2688
Mailing address:
  • Phone: 660-707-0280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number106544
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: