Healthcare Provider Details

I. General information

NPI: 1639565344
Provider Name (Legal Business Name): JUSTIN T CASTELLOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E 3900 S
MILLCREEK UT
84124-1300
US

IV. Provider business mailing address

1200 E 3900 S
SALT LAKE CITY UT
84124-1300
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-8063
  • Fax: 208-367-8067
Mailing address:
  • Phone: 208-367-8063
  • Fax: 208-367-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101264380
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101264380
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: