Healthcare Provider Details

I. General information

NPI: 1407083256
Provider Name (Legal Business Name): MAURICIO JOSE DE CASTRO PRETELT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE STE 5D
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

541 N CORNICHE DU LAC
COVINGTON LA
70433-7260
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4211
  • Fax: 405-271-2263
Mailing address:
  • Phone: 813-253-9291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number0101250567
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number46520
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number0101250567
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: