Healthcare Provider Details

I. General information

NPI: 1457188039
Provider Name (Legal Business Name): ERNESTO CASTELLANOS IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

IV. Provider business mailing address

1755 HUFFMAN AVE
DAYTON OH
45403-3109
US

V. Phone/Fax

Practice location:
  • Phone: 765-430-4516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: