Healthcare Provider Details

I. General information

NPI: 1508961442
Provider Name (Legal Business Name): JOE BLAIR CASTLES III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RICHLAND MEDICAL PARK DR STE. 410
COLUMBIA SC
29203-6877
US

IV. Provider business mailing address

14 RICHLAND MEDICAL PARK DR STE. 410
COLUMBIA SC
29203-6877
US

V. Phone/Fax

Practice location:
  • Phone: 803-799-9044
  • Fax: 803-256-8119
Mailing address:
  • Phone: 803-799-9044
  • Fax: 803-256-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22534
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: