Healthcare Provider Details

I. General information

NPI: 1821090333
Provider Name (Legal Business Name): GLENN Y CASTANEDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 FOX ST. SUITE 102
POUGHKEEPSIE NY
12601-4723
US

IV. Provider business mailing address

21 FOX ST. SUITE 102
POUGHKEEPSIE NY
12601-4723
US

V. Phone/Fax

Practice location:
  • Phone: 845-452-9750
  • Fax: 845-452-9751
Mailing address:
  • Phone: 845-452-9750
  • Fax: 845-452-9751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number217754
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number217754
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: