=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326268798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICARDO ESTEBAN CASTELLON INESTROZA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 S MAIN ST 4TH FLOOR OPC BUILDING
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-927-1284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 S MAIN ST 4TH FLOOR OPC BUILDING
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-927-1284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 23967
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | Q0230
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------